Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Edir DA Costa · 27 Jun 2019 · Nadia Persaud, London (East)
“Evidence was heard at the Inquest that errors were made in communicating information to the LAS.”
judiciary.uk/prevention-of-future-death-reports/edir-da-costa
What was promised
Stated action 1 · response to Edir DA Costa (27 Jun 2019) · stated timescale: April 2020
“request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance”
judiciary.uk/…/2019-0211-Response-by-Metropolitan-Police.pdf
Stated action 2 · response to Edir DA Costa (27 Jun 2019) · stated timescale: October 2019
“The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise)”
judiciary.uk/…/2019-0211-Response-by-Metropolitan-Police.pdf
Stated action 3 · response to Edir DA Costa (27 Jun 2019) · stated timescale: October 2019
“Future restraint lessons will reference the revised Module 12 of the National Personal Safety Manual (NPSM) which was presented by Inspector Collett during the Inquest as the final draft”
judiciary.uk/…/2019-0211-Response-by-Metropolitan-Police.pdf
1 further stated action is listed on the full chain page.
What recurred
- 26 Nov 2020 · Agnès Marchessou · Mary Hassell · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Edir DA Costa · 27 Jun 2019
“Evidence was heard at the Inquest that errors were made in communicating information to the LAS.”
Later · Agnès Marchessou · 26 Nov 2020
“The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms [name redacted] to hospital, nor to any of the doctors or nurses at the hospital.”
What happened next
No web check of the stated actions has been published for this chain.