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recurance

Choking risk from detainee substance in mouth

Closely relatedConfidence 0.85 · high3 reports · 2017–2025No published response to an earlier report One-page brief (print or PDF)

National Police Chiefs' Council received 3 coroners' reports about this hazard between 1 Mar 2017 and 4 Mar 2025.

They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.

A published response was found for 1 of the 2 earlier reports, stating 0 specific actions.

3
reports
3
different coroners
2017–2025
years
0.85
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Darran Hunt↗

    1 Mar 2017 · Gareth Lewis · Carmarthenshire and Pembrokeshire

    “There appears to be an apparent lacuna or, at least, confusion in respect of training for Police in relation to situations where a detained person puts a potentially harmful substance or item in their mouth.”
    Original on judiciary.uk ↗

    No published response from National Police Chiefs' Council was found for this report.

  2. 1 year 8 months later

    Raised again · 1st time

    Karl Brunner↗

    29 Oct 2018 · Martin Oldham · Bedfordshire & Luton

    Identical hazardConfidence 0.90 · higha different coroner
    “The evidence however | disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained.”
    Original on judiciary.uk ↗

    National Police Chiefs' Council responded.Response (PDF) ↗

  3. 6 years 4 months later

    Raised again · 2nd time

    Robert Evans↗

    4 Mar 2025 · David Lewis · Liverpool and Wirral

    Closely relatedConfidence 0.85 · higha different coroner
    “The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that "...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer then straight to hospital"”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Officersswallowed

    National Police Chiefs' Council responded.Response (PDF) ↗Response (PDF) ↗

  4. All reports to National Police Chiefs' Council

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error