Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0117, written 14 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2014 |
|---|---|
| Reference | 2014-0117 |
| Deceased | David Oldfield |
| Coroner | Melanie Williamson |
| Coroner area | West Yorkshire (East) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mark Gilmore, Chief Constable for West Yorkshire Police Force 1 | CORONER | am Miss Melanie J Williamson, Assistant Coroner, for the coroner area of West Yorkshire (Eastern) 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] 3 | INVESTIGATION and INQUEST On the 19" October 2012 an investigation was commenced into the death of David Robert Oldfield, aged 38 years. The investigation concluded at the end of the inquest on 12" March 2014. The medical cause of the Deceased’s death was:- 1(a) Shock and haemorrhage (b) Stab wounds to neck penetrating jugular vessels. The Jury returned a unanimous Open Conclusion. 4 | CIRCUMSTANCES OF THE DEATH During the early hours of the 5" October 2012 an incident took place at the Deceased’s home address involving the Deceased and his partner. In the course of the said incident both the Deceased and his partner sustained significant injuries. Emergency services were alerted and attended at the scene shortly after 4am on the 5" October 2012, including firearms officers with West Yorkshire Police Force who had been granted taser authority. Between 4.08am and 4.10am the Deceased was tasered after he had suffered fatal stab wounds to his internal and external jugular vessels on both sides of his neck, and extensive blood loss. The Deceased’s condition deteriorated and he passed away at 4.24am on the 5" October 2012 at 6 Poplar Square, Farsley, near Leeds. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) There is no evidence that the act of tasering the Deceased caused or contributed to his death; however, there is evidence that tasering can, in certain circumstances, cause serious injury and/or death to a person; (2) The tasering of a person by firearms officers should only take place in appropriate and justifiable circumstances, and a failure to do so unnecessarily increases the risk of a loss of life; (3) On the basis of evidence adduced in the course of the Inquest it is unlikely that the events immediately preceding the tasering of the Deceased occurred in the manner stated by one or more of the attending firearms officers; (4) Therefore, it is of concern as to precisely what were the circumstances which preceded the act of tasering the Deceased, whether such was appropriate and justifiable in all the circumstances and, if not, whether similar circumstances could arise in the future. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9" May 2014. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- (1) the Deceased’s next of kin, c/o Messrs Wilsons, 2-4 Fair Road, Wibsey, Bradford, BD1 1QN (2) Mark Gilmore, the Chief Constable for West Yorkshire Police Force of West Yo rters, Laburnum Road, PO Box 9, Wakefield, WF1 3QP/ (3) egal Services Manager of Springhill, Brindley Way, Wakefield 41 Business Park, Wakefield, WF2 0XQ. lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. NAA ———— DATE 14" March 2014 Melanie J Williamson Assistant Coroner
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
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West Yorkshire Police Headquarters “4.4,)
Laburnum Road
WEST YORKSHIRE layup
PO Box 9
Wakefield
WF1 3Qp
Tel; 01924 292023
Fax:
Chief Officer Team Email:
HM Assistant Coroner Williamson
HM Coroner's Office
71 Northgate
Wakefield
WF1 3BS
5 September 2014
Dear Miss Williamson
| write in reply to your letter and Regulation 28 report in respect of the inquest touching the death of David
Robert Oldfield. We also sought and received further clarification from yourself concerning the points you
raised and | attach copies of all the correspondence to assist.
i had hoped to respond earlier but our senior officer with responsibility for professional standards who was
dealing with the matter has recently moved to the National Crime Agency and | needed to first meet with
his successor which has had to be postponed due to leave and operational matters. | apologise for the
delay.
Your regulation 28 report highlighted four matters of concern:
The further comments we received from you in relation to the first two (the safe usage of Taser and the
importance of its use in appropriate and justifiable circumstances) made it clear that these required no
additional response from us, but were to highlight issues for our awareness. | will however return to these
at the conclusion of the letter.
Issues three and four related to the accounts given to the Inquest by officers PY and
HEEB in relation to the circumstances immediately preceding the use of the Taser. The fact that you
were raising concerns regarding the evidence of these officers was clearly a matter of importance to us
and one which we would seek involvement of the IPCC to ensure independence and transparency:
By coincidence, | was the senior officer on duty on the morning of the incident and was informed of it as |
was travelling in to work. | therefore went directly to the Command Room and ensured the IPCC were
informed immediately given the circumstances — and which in any event required a mandatory referral.
The scene and the post mortem were attended by an IPCC investigator in. The IPCC
investigated the circumstances over a period of 3 days (including the date of the incident) before deciding
that it was appropriate for a local investigation by the force. The investigation would have been retained by
them, had they had concerns over the use of the Taser.
As your regulation 28 report and clarifying letter has commented on the evidence the officers gave ait the
Inquest, | asked my head of professional standards to again review the case and to forward your
correspondence to the IPCC. On the basis of this, the IPCC did not consider that the matter should be
further referred to them. They did however state that their view may be different if:
{i} You were alleging any dishonesty on the part of the officers’ evidence (which may amount to
perjury or conspiracy to commit perjury).
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(ii) Whether there was evidence to support this or whether it was it was a matter of the differences in
the evidence or interpretation of the facts given by the officers.
(iii) Full transcripts were available for review.
We have again spoken with the barrister acting on our behalf, as the solicitor with conduct of the case was
not in court at all times, and read the notes made by the solicitor who was in attendance when the officers
gave evidence. This has not identified concerns about the officer's evidence. Whilst we accept that the
accounts of these officers had differences (which were open to cross-examination) we believe these
differences were in the nature of normal differences in witnesses’ accounts rather than anything more
sinister. It may be pertinent that the officers who used the Taser were authorised firearms officers with
significant training and experience in dealing with serious incidents such as the tragic events that morning,
whereas the divisional officers were not so and indeed were in fear at the time, which can affect the
perceptions of events. Although we would often seek to portray the professionalism and bravery of police
officers, they are human as well. In making these observations, ! do so merely to illustrate, accepting that |
was neither at the incident nor the inquest. | recognise that it is entirely your prerogative as coroner to
consider if there are any further matters (described in the preceding paragraph) to be forwarded to the
IPCC.
Finally | return to the safe and appropriate usage of Taser issues covered at the beginning of my letter. |
was aware that in the inquest, our evidence was mainly concerned with what had happened in connection
with the sad events of the morning itself. Exploration of contextual issues such as our tactical training of
Taser and the differences between deployments by authorised firearms officers compared with divisional
officers may have been of assistance to the inquest. As the senior lead for West Yorkshire on Taser | am
aware that its use is not widely understood and that we need to be open in explaining how it contributes to
making the public safe. For example the force receives about a thousand “999” calls every day, yet on
average we fire a Taser between once or twice a week. | would therefore offer the opportunity for you to
visit our training facilities at Carr Gate in order to see for yourself how we train and use the Taser.
| hope that | have been able to clarify your concerns
Yours sincerely
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