Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0311, written 2 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jul 2014 |
|---|---|
| Reference | 2014-0311 |
| Deceased | Hywel Hughes |
| Coroner | Karon Monaghan |
| Coroner area | North West Wales |
| Category | Police 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Constable of the North Wales Constabulary 2. The Security Industry Authority 3. The Secretary of State for the Home Department CORONER | am Karon Monaghan QC, Assistant Coroner, for the Coroner area of North West Wales 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. INVESTIGATION and INQUEST An investigation into the death of Mr Hywel LLewelyn Hughes (date of birth 11 January 1971) concluded at the end of the Inquest on 26 June 2014. The conclusion of the inquest was that: (i) the medical cause of death was traumatic asphyxia; (ii) the actions of police officers attached to the North Wales police force on coming upon Mr Hughes were not appropriate and (iii) it is more probable than not that the actions of the police officers more than minimally contributed to the death of Mr Hughes. CIRCUMSTANCES OF THE DEATH On 2 May 2003, Mr Hywel LLewelyn Hughes was forcibly removed from Joops nightclub, Bangor, by employed members of the door staff at about 23.10. After a struggle with two members of the door staff between approximately 23.10 and 23.18, he was restrained by them in a face down position on the road. During the period of this restraint, he was unable to breathe and suffered injuries which ultimately caused his death. Two police officers attached to the North Wales police force arrived on the scene at approximately 23.18 and transported Mr Hughes to Caemarfon police station from where he was conveyed to Ysbyty Gwynedd, arriving at approximately 00.30. Mr Hughes was declared deceased at Ysbyty Gwynedd at 19.30 hours on 3 May 2003. 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) The training on positional asphyxia presently provided to police officers by the North Wales Police Force does not include guidance on the significance of ‘snoring’ and in particular that it is not inconsistent with deep unconsciousness and obstruction to breathing. (2) The design of the ‘bubble cars’ in existence at the time of Mr Hughes’ death and apparently still in use pending their phasing out, is such that the condition of a detainee held in the rear of the vehicle may not be easily monitored (because of the presence of a Perspex screen that may affect the ability to see and hear a detainee). (3) The design of the new ‘bubble cars’ may impede an officer's ability to hear a detainee (and thus identify irregularities or difficulties in breathing) because of the presence of a (albeit smaller) Perspex screen. (4) Twenty deaths apparently related to and/or following restraint by door supervisors have occurred since the introduction in 2004 of (rolled out) compulsory licensing of door supervisors, by the Security Industry Authority (“SIA”) (established by the Private Security Act 2001, in 2003). There have been four restraint related deaths involving twelve door supervisors (all of whom have been charged with either murder or manslaughter) since April 2013, that is, following the introduction (in February 2013) of mandatory training as a condition for the awarding (or renewal) of a licence to work as a door supervisor anywhere in the UK. (5) The SIA does not undertake any review or inquiry into those deaths indicated by Inquest or criminal findings to be related to restraint by door supervisors to determine whether there are any lessons to be learmt in so far as their licensing or other responsibilities are concerned. (6) The SIA’s standards of conduct, training and levels of supervision issued pursuant to their statutory responsibilities under section 1(2)(e) of the 2001 Act, namely the “Specification for Leaming and Qualifications for Door Supervisors” (Feb 2010) and the “Specifications for Learning and Qualifications for Physical Intervention Skills’ (Aug 2010), do not include a requirement for training or knowledge on the dangers inherent in restraint, specific modes of restraint, positional asphyxia or traumatic asphyxia. 7) The SIA does not audit the training provided to door supervisors b accredited training providers, particularly on issues of restraint and | asphyxia (traumatic and positional). (8) The mandatory training that door supervisors are required to undertake as a condition of the award of a licence by the SIA does not integrate training on asphyxia into the training on restraint (it is addressed by a limited and discrete element). (9) The licensing requirements for door supervisors do not include a requirement for a first aid qualification. (10) lt is not clear that all persons presently working as door supervisors have yet undertaken physical intervention training (it appears that those who already have a licence will only be required to undertake ‘top training’ when they seek renewal of a licence). (11) There have already been four ‘Rule 43’ reports to the SIA by Coroners conceming the training of door supervisors on restraint and asphyxia. : In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. 7 taken, setting out the timetable for action. Otherwise you must expl ACTION SHOULD BE TAKEN YOUR RESPONSE | You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 August 2014. |, the Assistant Coroner, may extend the period. Your response must contain details of action taken or proposed to be jain 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: A PON> | have also sent it to HM Coroner for North West Wales and to the British Security industry Association who may find it useful or of interest. | am 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 C: 2 July 2014 Karon Monaghan QC
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.
Gareth Pritchard MA Dirprwy Brif Gwnstabl / Deputy Chief Constable Our ref: DCC/ND/HHCorInqFinal14 21st August 2014 Email: Dear Madam Hywel Llewelyn Hughes We refer to your Schedule 5, Regulation 28 report to prevent future deaths dated 2 July 2014 and in particular the parts addressed to North Wales Police (“NWP”). We reply as follows:- a) Snoring NWP agree that in the light of the evidence/findings arising from this inquest that snoring should be including in the training on positional asphyxia. Therefore, NWP have:- • Amended their first aid, personal safety and tasar training materials and training package to add snoring as a symptom of positional asphyxia. • Added an exercise in which a violent person stops breathing after being dealt with by officers to the tasar and personal safety training to demonstrate the dangers of such medical emergencies. The NWP amendments on snoring have been recommended to the organisations below to bring about improvement to material/training at a national level for police forces. o College of Policing o The National Secretary and Regional Representative for the Self Defence Arrest and Restraint section of the Association of Chief Police Officers (“ACPO”) o The North West Regional Firearms Group www.heddlu-gogledd-cymru.police.uk Swyddfa’r Dirpwy Prif Gwnstabl Pencadlys yr Heddlu, Glan-y-Don, Bae Colwyn LL29 8AW Ffôn (Cymraeg): L.U.: www.north-wales.police.uk Deputy Chief Constable’s Office Police Headquarters, Glan-y-Don, Colwyn Bay LL29 8AW Tel (English): Direct Dial: b) Bubble Cars NWP consider that police officers can effectively monitor detainees irrespective of the issues highlighted over sight and hearing connected to the protective screens in the existing double compartment bubble car or proposed single compartment bubble car when transporting detainees. Monitoring is achievable to acceptable levels if officers pay sufficient attention to the task and abide by their detainee risk assessments and force policies when transporting detainees. However, NWP are considering improvements to assist with monitoring as set out below. Bubble cars are general purpose police vehicles lawfully modified to utilise a containment cell for prisoners within the vehicle. The protective screen in bubble cars’ containment cells (between the detainee and the driver/passenger police officer) are made of polycarbonate not perspex. The protective screens were designed as part of the containment cell arrangement to achieve a sensible balance between health and safety concerns for the police officers and the detainees whilst providing an acceptable capacity for monitoring detainees. NWP operate in a large rural area, utilising three designated custody suites in convenient locations within their force area. NWP consider bubble cars as a preferable alternative to police vans for transporting detainees for a number of reasons. The force are presently evaluating changing the containment cell from a double one to a single cell, however, a final decision on whether this goes ahead will be dealt with after testing and further consideration is concluded. It is not correct to suggest that the double cell bubble cars are being “phased out”. The screen is not scratch resistant but a sharp instrument would be needed to scratch it. Bubble cars are the subject of a vehicle user check for each day by the police officer utilising the vehicle and a weekly check by a supervising sergeant. The user check includes the protective screen. Defects are reported to fleet services which result in repairs being undertaken in a timely fashion, which include scratches on the protective screen. NWP have assessed the protective screen as adequate to hear a detainee within the containment cell. The bubble cars used over the years have altered because of fleet services procurement requirements. The latest vehicle being utilised was the Ford Focus, which due to manufacturer redesigns resulted in less cabin space due to the area occupied by the compartment cell. This lack of space resulted in complaints from taller officers that there was insufficient room for the front seats to be put back sufficiently. There was also concern about a number of incidents in which violent detainees had kicked out the rear nearside and offside windows and with drunken detainees slumping across the rear seats, making monitoring more problematical. Accordingly, to assist with these problems, NWP have designed a single cell compartment bubble car in conjunction with the manufacturer and are testing the single cell compartment, which appears so far to present significant improvements to the existing double cell compartment arrangement. It allows better monitoring as the police officer is closer to the detainee from visual and auditory perspectives. Proposed auditory Improvements NWP are considering the following:- • Scoping an automated intercom solution with a view to identifying an appropriate product to be tested on a demonstrator vehicle for use in the bubble containment cell; • Undertaking enquiries as to the possibility of having a hole in the protective screen to see if that improves ability to monitor detainees (and does not compromise the integrity of the protective screen or provide health and safety implications for the police officers/detainees). Finally, the Police and Crime Commissioner (“PCC”), Winston Roddick QC wishes to make it clear that he will scrutinise NWP’s response to your report by examining its revised training programme to satisfy himself that the revisions have been adopted and the training is being carried out in accordance with those revisions. He proposes to make unannounced visits to force training sessions to verify their adequacy. Similarly, the PCC will satisfy himself that NWP’s use of the bubble car, whether in a double or single compartment, including any improvements to the polycarbonate screen and/or intercom arrangements, are adequate. Yours faithfully Deputy Chief Constable
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