PFD report

Marc Antony Cole · Prevention of Future Deaths report

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Issued 6 Feb 2020•Cornwall and Isles of Scilly

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Report evidence summary

Concerns raised3

  1. Insufficient independent data on the effects and lethality of Taser use
    Part of recurring concern: Inadequate safety controls for Taser use
  2. Failure of police training to specify safe limits for the number and duration of Taser activations
    Part of recurring concern: Inadequate safety controls for Taser use
  3. Lack of understanding of incremental risk from multiple Taser activations
    Part of recurring concern: Inadequate safety controls for Taser use
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.5

  1. Action

    Provide College guidance addressing risks from repeated and prolonged Taser discharges.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 20 April 2020.
  2. Action

    Provide Taser learning materials covering discharge duration, repeated activations, medical risks, vulnerable people and aftercare.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 20 April 2020.
  3. Action

    Continue working with SACMILL so Taser guidance and training reflect current independent scientific evidence.

    Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 20 April 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    College training is not silent on the risks associated with multiple or prolonged Taser activations.

    Stated by College of PolicingDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Insufficient independent data on the effects and lethality of Taser use

Wider context from the report

“It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable). In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe. The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’). It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear. Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part. Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available. I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete. ”

Is this part of a recurring concern?

Yes — Inadequate safety controls for Taser use.

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

Failure of police training to specify safe limits for the number and duration of Taser activations

Wider context from the report

“It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable). In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe. The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’). It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear. Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part. Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available. I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete. ”

Is this part of a recurring concern?

Yes — Inadequate safety controls for Taser use.

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 understanding of incremental risk from multiple Taser activations

Wider context from the report

“It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable). In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe. The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’). It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear. Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part. Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available. I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete. ”

Is this part of a recurring concern?

Yes — Inadequate safety controls for Taser use.

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

Provide College guidance addressing risks from repeated and prolonged Taser discharges.

Verbatim wording from the response

“College learning materials and guidance do address the risks associated with the number and duration of Taser activations. Section 3 and 4 below set out the relevant materials the College has provided to police forces. They are in line with the medical implications and advice provided by SACMILL.”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 3 · response
Published 20 April 2020

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 Taser learning materials covering discharge duration, repeated activations, medical risks, vulnerable people and aftercare.

Verbatim wording from the response

“Section 4. Learning materials”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 4 · response
Published 20 April 2020

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 working with SACMILL so Taser guidance and training reflect current independent scientific evidence.

Verbatim wording from the response

“We would like to thank you for bringing the circumstances of Mr Cole’s death to our attention and we will ensure that our immediate and future work is informed by the events that culminated in Marc’s tragic death. We keep Taser training under regular review and we will carefully examine the findings of Mr Cole’s inquest to ensure learning continues to be reflected. The College will also continue to work with SACMILL to ensure that our guidance and training are always informed by the most up-to-date independent scientific evidence available to us.”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 1 · response
Published 20 April 2020

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

Keep Taser training under regular review.

Verbatim wording from the response

“We would like to thank you for bringing the circumstances of Mr Cole’s death to our attention and we will ensure that our immediate and future work is informed by the events that culminated in Marc’s tragic death. We keep Taser training under regular review and we will carefully examine the findings of Mr Cole’s inquest to ensure learning continues to be reflected. The College will also continue to work with SACMILL to ensure that our guidance and training are always informed by the most up-to-date independent scientific evidence available to us.”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 1 · response
Published 20 April 2020

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Introduce transparency measures requiring recording and annual publication of police use-of-force data.

Verbatim wording from the response

“In 2017, we introduced new transparency measures, which mean that all officers have to record the location and outcome of all police use of force, along with the ethnicity and age of those involved. Use of force incidents, are recorded by all 43 Home Office police forces in England and Wales and reported to the Home Office annually. This data is published annually, the most recent publication was 19 December 2019⁷.”

Source location

2020-0087-Response-from-the-Home-Office
Page 5 · response
Published 20 April 2020

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

College training is not silent on the risks associated with multiple or prolonged Taser activations.

Verbatim wording from the response

“2.1: No training provided as to the maximum number of activations nor of their duration which is appropriate or safe. The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 3 · response
Published 20 April 2020

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

The Home Office and SACMILL are better placed to comment on the evidence and whether further Taser research is required.

Verbatim wording from the response

“In performing its role SACMILL has taken account of a body of evidence relating to the use of Taser. The College is not able to comment on the detail of the evidence that has been reviewed. The Home Office and SACMILL would be better placed to comment on the detail of the evidence and as to whether any further research is required.”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 4 · response
Published 20 April 2020

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 College guidance and learning materials address Taser activation risks and align with SACMILL medical advice.

Verbatim wording from the response

“In summary, my detailed response explains that current College guidance and learning material address the risks associated with the number and duration of Taser activations. Our materials have been developed in close consultation with the independent body (SACMILL*) that advises the Home Office on the medical issues associated with conducted energy devices and are in line with their advice. The Home Office and SACMILL would be better placed to comment on the evidence base.”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 1 · response
Published 20 April 2020

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

Definitive guidance on the number and duration of Taser discharges cannot be given because influencing factors are numerous and varied.

Verbatim wording from the response

“The point should be made that it is not possible to give officers definitive guidance on the number and duration of discharges, as the factors that would influence this decision are many and varied. We take the position that every discharge must be lawful, necessary and proportionate to the threat posed and be informed by the risk factors identified, where possible. However, some risk factors may not be immediately apparent to the officer, meaning that it is not possible to account for them. We reiterate the SACMILL position that Taser activation should be minimised to reduce risk, however it is not possible to eliminate all risk.”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 5 · response
Published 20 April 2020

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 Taser medical evaluations, guidance, training and ongoing scrutiny are considered adequate to ensure police use of force is as safe as possible.

Verbatim wording from the response

“I am grateful to you for highlighting your concerns about the use of Taser. As you would expect, we take seriously your concerns concerning the circumstances of Mr. Cole’s death. We have carefully reviewed the processes and safeguards in place for the police use of Taser, including the independent evaluations of the medical implications of Tasers carried out by SACMILL, the guidance available, the high standards of training, and the ongoing scrutiny of the Taser use. I am satisfied that they are adequate and help ensure that any use of force by the police is proportionate, necessary and as safe as possible.”

Source location

2020-0087-Response-from-the-Home-Office
Page 7 · response
Published 20 April 2020

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

    Examine the inquest findings and reflect resulting learning in immediate and future work.

    Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 20 April 2020.
  2. 2

    Approve and publish a statutory Code of Practice governing selection, evaluation, approval, authorisation, acquisition and deployment of less-lethal weapons.

    Stated by Home OfficeStated completedThe respondent said that this action was complete when they made their response on 20 April 2020.
  3. 3

    Continue working with the College of Policing and National Police Chiefs’ Council to reduce risks associated with less-lethal weapons.

    Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 20 April 2020.

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

Examine the inquest findings and reflect resulting learning in immediate and future work.

Verbatim wording from the response

“We would like to thank you for bringing the circumstances of Mr Cole’s death to our attention and we will ensure that our immediate and future work is informed by the events that culminated in Marc’s tragic death. We keep Taser training under regular review and we will carefully examine the findings of Mr Cole’s inquest to ensure learning continues to be reflected. The College will also continue to work with SACMILL to ensure that our guidance and training are always informed by the most up-to-date independent scientific evidence available to us.”

Source location

2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Page 1 · response
Published 20 April 2020

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

Approve and publish a statutory Code of Practice governing selection, evaluation, approval, authorisation, acquisition and deployment of less-lethal weapons.

Verbatim wording from the response

“On the 14 January 2020 the Home Secretary approved a new Code of Practice for Armed Policing and Police Use of Less Lethal Weapons³. The Code makes clear that all new less lethal weapon systems, certain specialist munitions and systems designed to pre-approve less lethal weapons systems require approval by the Home Office before they can be used by police forces in England and Wales.”

Source location

2020-0087-Response-from-the-Home-Office
Page 4 · response
Published 20 April 2020

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 working with the College of Policing and National Police Chiefs’ Council to reduce risks associated with less-lethal weapons.

Verbatim wording from the response

“We will continue to work with the College of Policing and National Police Chief’s Council to reduce the risks associated with the use of less lethal weapons such as Taser.”

Source location

2020-0087-Response-from-the-Home-Office
Page 6 · response
Published 20 April 2020

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

Official responses located
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Data last updated 7 September 2026