Neal Saunders
15 Dec 2022 · Coroner Heidi Connor · Berkshire
The coroner's concerns
1. prolonged restraint
“There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, (and presumably to the jury, given their conclusion), that the officers at the scene were trying to take [the deceased]'s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining [the deceased], at least initially, it was clear from the evidence that none of the officers recalled their training which”
2. undefined prolonged restraint
“The training gives no guidance as to what constitutes”
3. guideline applicability uncertainty
“One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding”
4. incorrect category 1 expectation
“The College of Policing slides regarding ABD state that a”
5. misunderstanding of chemical sedation
“The guidelines also refer to providing”
6. training effectiveness verification
“Is there a better way for the College of Policing to ensure that the training has worked and is embedded?”
Responses
2022-0401-Response-from-College-of-Policing-.pdf ↗· College of Policing
2022-0401-Response-from-South-Central-Ambulance-Service-.pdf ↗· South Central Ambulance Services and Association of Ambulance
2022-0401-Response-from-Thames-Valley-Police.pdf ↗· Thames Valley Police
Stated action
“The College of Policing have advised that there is no set definition for 'prolonged restraint'. As a result, and on the advice of , the teaching outlined below will be based on the assumption that within individuals, the physiological changes that can take place during restraint are dynamic, in that they are different for each person and in each situation. The teaching will reinforce Officer's staying alert to the needs of the subject at all times.”
Stated action
“At any incident, Officers will have a range of tactical options available to them in terms of the subject management. Using the National Decision Model (NDM), Officers will decide on what tactic(s) may be necessary, justified, proportionate and legitimate. The decision to contain rather than restrain is for the Officer to consider, and applies whether the subject is under arrest or not. The Training 2 material on this issue has been updated to ensure that Officers understand this point”
Stated action
“Guidance received from SCAS and the AACE has clarified the nationally mandated list of Category 1 call 'types' and the descriptions. The AACE have confirmed that ABD would be classified as a Category 2 incident. This will only be upgraded to a Category 1 if the clinical picture dictates it. As a result, TVP's teaching materials have been changed to place greater emphasis on the signs and symptoms of ABD and the physical effects of restraint.”
Stated action
“The original references to ABD being classified as a 'Cat 1' Ambulance Response and the use of 'chemical sedation' which was included in the CoP's ABD E-Learning package, have been removed by TVP and training materials updated in accordance with the guidance from SCAS and the AACE. As such, it will still be taught that ABD is considered a medical emergency.”
Stated action · 14th November 2023
“TVP's response includes new learning materials and programmes for all frontline Officers and Staff who have direct contact with the public. This learning will be blended learning which will include classroom-based inputs, supported by written material and subject to practical assessments, which will include a physical scenario to consolidate learning as set out below.”
Stated action · end of March 2024
“In April 2023, the College of Policing are introducing a new PPST 2-day training and assessment re-accreditation programme for all Forces nationally. The new programme will be based around six scenarios to aid officer's learning and the retention of knowledge and skills. Forces have until the end of March 2024 to introduce the new programme, which is due to go live in TVP on 14th November 2023.”