Prevention of Future Deaths reports · 2014

Ryan Boyle

Regulation 28 report to prevent future deaths, reference 2014-0263, written 9 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Jun 2014
Reference2014-0263
DeceasedRyan Boyle
CoronerSimon Wickens
Coroner areaSurrey
CategoryPolice related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquests Touching the Death of Ryan Patrick BOYLE
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
The Chief Constable of Surrey Police
1 CORONER
Simon Wickens HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3 INVESTIGATION and INQUEST
The inquest into Ryan Boyle’s death was opened on the 27th February
2013 and was concluded, following an adjournment, on the 6th June 2014.
The cause of death was:
1a – Head Injury.
The Jury concluded with a narrative conclusion:
On 21st February 2013 at approximately 7.43pm, Ryan Patrick Boyle was
driving a silver Lexus alone in South Godstone.
Following observation by a stationary unmarked police vehicle and a
prolonged visual interaction with the police officer, suspicion was
aroused and a moving vehicle check was initiated.
As a result of the moving vehicle check, the Force Control Room (FCR)
Operator informed the police vehicle that the Lexus had a void record;
the police officers decided they wished to stop the Lexus.
Blue lights and sirens were put on and a pursuit commenced.
The Dynamic Risk Assessments made by the police were adequate and
the Dynamic Risk Assessments by the FCR were insufficient.
On the balance of probabilities, it was acceptable for the pursuit to
continue.
RT4060 1
Ryan Patrick Boyle died as a result of a Road Traffic Collision.
4 CIRCUMSTANCES OF THE DEATH
On 21st February 2013 at approximately 7.43pm Mr Boyle, a 19 year old
cable engineer, was driving his uninsured motor vehicle on the A22. He
was pursued by an unmarked Surrey Police vehicle and the Officers
conducted a moving check upon it. Following receiving information the
vehicle had a ‘void’ marker, the Officers decided to stop the vehicle. Mr
Boyle continued driving at speed despite the use by the Police vehicle of
lights and sirens and was subsequently involved in a road traffic collision
with other road users. The Jury found that the dynamic risk assessments
conducted by the Force Control Room were insufficient.
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed a number matters
that gave rise to a concern that circumstances creating a risk of other
deaths will continue to exist in the future unless action is taken.
The MATTERS OF CONCERN are as follows. –
1. Action is required to ensure that ALL force control operators and
those likely to deal with a police pursuit are sufficiently trained
and/or re‐trained so that they understand their responsibilities,
powers and obligations under force policy when dealing with a
pursuit.
2. Action is required to ensure that there is an efficient and effective
notification system (beyond the current practice of shouting) for
controllers to notify supervisors and/or other members of Force
Control Room staff that a pursuit has commenced.
3. Action is required to ensure that a minimum of two persons are
monitoring the ‘Force desk’ at all times so as to allow effective
dealing with any pursuits that might arise.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the Chief Constable of Surrey Police has the power to take such
action.
RT4060 2
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to :
– Force Solicitor, Surrey Police
The Chief Coroner.
9 Signed:
Simon Wickens
DATED this 9th day of June 2014
RT4060 3

Responses

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.

Response from Surrey Police (PDF)
SURREY

POLICE

Force Solicitor
25 July 2014

HM Coroner for Surrey, Mr Wickens
HM Coroner’s Court

Station Approach

Woking

GU22 7AP

Dear Mr Wickens

Thank you for your letter dated 9 June 2014 enclosing your Report to Prevent Future
Deaths following the inquest into the death of Ryan Boyle. In your report you raised
three matters of concern and suggested that action should be taken in relation to

those matters of concern as follows:

e Action is required to ensure that all force control operators and
those likely to deal with a police pursuit are sufficiently trained
and/or re-trained so that they understand their responsibilities,
powers and obligations under force policy when dealing with a

pursuit.

e Action is required to ensure that there is an efficient and
effective notification system (beyond the current practice of
shouting) for controllers to notify supervisors and/or other
members of Force Control Room (“FCR”) staff that a pursuit

has commenced.

e Action is required to ensure that a minimum of two persons are
monitoring the Force Desk at all times so as to allow effective

dealing with any pursuits that might arise.

Legal Services Department Surrey Police, PO Box 101, Guildford, Surrey GU1 9PE
| TS TIT 0c: ven suey policeuk

| can report that the following steps have been taken to address the concerns which

you have raised.

Training

Since the tragic case of Ryan Boyle Surrey Police have entered into collaborative
working arrangements with Sussex Police which is now formalised through a s.22A
Police Act 1996 agreement in pursuance of s.23 Police Act 1996. This effectively
requires the lead Force to set future policy on behalf of both. In the case of pursuits
this is the responsibility of Sussex as the Lead Force Operations and Road Policing.

The Surrey Police Guidance on Pursuit Management has therefore been reviewed to
ensure that it is fully consistent with the Association of Chief Police Officers
Guidance on the Management of Police Pursuits, as well as Sussex Police Pursuit
Policy. Where necessary, minor amendments have been made to ensure complete
consistency, with one exception regarding the authorisation of pursuits that | outline

below.

Following consultation with Superintendent mz Road Policing Operational
Command, Chief Inspector J Surrey Police Communications Department and
Chief Inspector J Sussex Police Communications Department regarding
Tactical Pursuit and Containment (“TPAC’) policy and training it has been agreed
that in Surrey only Ops 1 and Ops 2 will authorise a pursuit. Whilst this is
inconsistent with national (ACPO) policy which permits control room operators to
“authorise a pursuit where a supervisor is not immediately available” it is the
considered view of Superintendent m7 Chief Inspector [EEE and Chief
Inspector that permitting and/or requiring control room operators to
authorise pursuits would not be operationally desirable because expanding the
number of people who can authorise a pursuit increases the risk of inconsistency to
an unacceptable degree. The Surrey Police policy on TPAC therefore remains that
only Ops 1 and Ops 2 can authorise pursuits (though operators can discontinue
pursuits). The risk of there being neither an Ops 1 nor an Ops 2 available has been
examined and assessed to be very low and so | am satisfied that this is the safest
and most operationally effective system for Surrey.

The FCR Pursuit and TPAC Refresher 2014 have been fully revised and updated
(June 2014) to ensure that the Force’s training materials are up-to-date and clear on

the responsibilities, powers and obligations of FCR staff at all levels (operators, Ops
1, and Ops 2).

All FCR staff undertake training days annually and the results are recorded.

When addressing staffing shortfalls in the FCR, the Force uses police constables
who have previous FCR experience. All constables who are in the pool of officers
which can be drawn upon as an FCR staffing resource will be required to complete
the FCR training days along with full-time members of FCR staff. Action has been
taken to schedule training for these individuals in the next training cycle in
September/October 2014 and thereafter on an annual basis.

In the meantime all members of the pool:

e have been provided with a copy of the most recent training
materials and have been required to acknowledge receipt and
confirm that they understand the contents of the training

materials;

e will, on their next shift in the FCR, be given a one-to-one
session by the Ops 2 on duty who will take them through the
training materials and check their understanding of the contents
of the training materials. Records will be kept to note that this
has been completed.

The FCR supervisors will ensure that officers in the pool will not be routinely
deployed to the Force Desk. This role will be undertaken by FCR operators wherever

possible.

Notification system

A “Call Supervisor’ button has been installed at the top of radio channel
management screen on all FCR operator terminals. If the operator presses this
button then a corresponding alert button flashes up on the Ops 1 and Ops 2
terminals. This alerts Ops 1 and Ops 2 that there is an incident occurring within the
FCR (such as pursuits/firearms) that requires their immediate attention and
intervention.

The Force has consulted with the FCR Inspectors/Chief Inspectors in Hampshire,
Cambridgeshire, Dorset, Thames Valley, Sussex and Kent Constabularies, as well
as the Metropolitan Police to investigate best practice in the FCRs of other forces.
After detailed consideration Surrey Police remains of the view that the single most
effective means of alerting Ops 1 and Ops 2 to an incident requiring their attention
(e.g. firearms/pursuits) is by shouting to them. Clearly, this method is effective even
when the OPS 1 is not in physical sight of their terminal and acts as an additional
safeguard over and above the alert button that has now been installed. Therefore all
FCR staff have been instructed that ifAwhen they need to alert Ops 1 or 2 to an
incident they should always shout to them, but that that they should also press the
‘Call Supervisor’ button as well as a means of attracting attention. The importance of
making sure that they have been acknowledged by their supervisors is also

emphasised.

The functioning of this system will be monitored and kept under review and the

review recorded.

Staffing of Force Desk

All FCR staff and supervisors have been briefed that two people must physically
monitor the Force Channel at all times. The practical arrangements for putting this
into effect have been notified to all staff, including that if necessary Ops 2 must step

in to monitor the Force Channel.

A standing operating procedure has been drafted setting out the responsibilities of
Ops 2 for providing cover for the Force Channel where one of the operators has
temporarily left the Force Desk.

This system is being monitored and will be reviewed, and the review recorded, to
ensure that it is functioning properly.

| am grateful to you for having brought these matters to my attention and | hope that

this response is helpful.

Yours sincerely

Force Solicitor

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