Christopher Taylor

AVON AND SOMERSET CONSTABULARY

www.avonandsomerset.police.uk

Temporary Deputy Chief Constable

PO Box 37, Valley Road, Portishead, Bristol BS20 8QJ
Telephone: 101 Facsimile: 01275 816112

Office Hours: 8am — 6pm

M E Voisin
Our ref:

Her Majesty’s Senior Coroner for the Area of Avon
The Coroner’s Court

The Courthouse

Old Weston Road

Flax Bourton

BS48 1UL

Dear Ms \licin ;

In the matter of the death of Christopher David Taylor

25" March 2015

{ thank you for your letter dated 13" February 2015 and formally acknowledge receipt of your report
made under Regulation 28.

| immediately recognise the circumstances leading to Mr Taylor’s tragic death are such to demand proper
consideration is given as to how the risk of similar events re-occurring can be addressed. | would like to
assure you and, through you Mr Taylor’s family, that on behalf of Avon & Somerset Constabulary we take
the process of learning lessons very seriously in order to collectively better serve our community.

In preparing this response | have reviewed the written statements submitted on behalf of the ’
Constabulary. Without equivocation, | share your assessment that any delay, such as this where there is
no explanation, should not happen. The actions I’ve outlined below are those that have been initiated
since Mr Taylor’s death and which | consider address the risks that are at the heart of your report.

Communications

In his written evidence to the Inquest, inspector lifi/# outlined the phases through which a call such as
this would have progressed at that time. For your ease of reference however, Inspector HB informed
the Inquest that Force Service Centre (‘FSC’) was the ‘primary point of contact for all emergency [calls]
that come into the Constabulary.’ Designed to ‘offer a comprehensive service for the public contact the
Police’, FSC takes ‘on average 2500 to. 3000 call per day’, which is roughly one call every 25 — 30 seconds.
(t is evident enough from the calls logs disclosed to the Inquest, that the call taker’s actions were efficient
in gathering relevant information and prompt in transferring the call on for dispatch.

As per Inspector [J statement, once the call has been ‘taken’ it is transferred to from FSC to Dispatch,
which is sited in different locations away from FSC. The disparity between the call taker’s actions and the
period of approximately 5 minutes during which no recorded action appears to have been taken is the
first area the Constabulary has sought to address.

It appears to me the risks of calls to be ‘dropped’ will be significantly lessened with Call Handlers and
Dispatchers located together. Thus, from April 2015 the Constabulary will commence with the co-location
of Call Handlers and Dispatchers who will then work as one team under a single supervisor. The
unification of the two aspects of Communications will better enable information to be shared, ensure
clear accountability of decision making and promote holistic thinking. in terms of these events, | consider

that co-location with single supervision is likely to have the effect of minimising the risk of an
undocumented delay recurring.

Secondly, the Constabulary is introducing a new THRIVE (Threat, Harm, Risk, Investigation, Vulnerability,
Engagement) call grading matrix, as is in use by other Forces nationally. The focus of this new grading
matrix is to ensure deployment decision making is in line with threat, harm and risk. in the context of this
system should operate to ensure that decision making processes, such as that which lead to the decision
to call the ambulance service, are prompted at every stage.

Thirdly, and in order to best embed effective use of THRIVE, the Call Handling role has been re-written to
require a greater range of skills and capacity, such as were in evidence in this case. All new staff recruited
into this role will be trained in accordance with the enhanced requirements.

Fourthly, and in addition to the revamping of the Call Handler role, we are investing in our staff in rolling
out a comprehensive scheme of training for Call Handlers and Supervisors to enable the modifications to
their respective roles to be supported by learning.

Finally, and perhaps most fundamental to the redesigning of our communication services, from April 2015
the Constabulary will adopt a new call scripting system which is designed with flags, tags and alerts for
the benefit of the Call Handler/Dispatch team’s ability to dynamically and continually assess of
needs/priority of any one call.

lf taken in isolation, none of the above steps comprehensively addresses the specific concern in your
report that staff may not be able to ‘see at all-times a screen which displays incoming incidents.’
However, | hope you would share my view that when put into operation in concert with each other, the
cumulative effect is such that staff no-longer rely solely upon visual access to any specific screen.

Organisational Learning

Though not as a direct result of these tragic events, | would also wish to impress upon you the
Constabulary’s renewal approach to Organisational Learning, for which | am the portfolio lead. From
February 2015 the Constabulary’s approach to Organisational Learning has been refreshed with the
establishing of one consolidated Learning Board, which | lead, with wide ranging terms of reference
intended to capture and drive forward lessons from events such as this. To ensure the engine room for
corporate learning and change remains fuelled, each separate portfolio within the Constabulary has its’
own Learning Forum with a similarly wide remit to feed into the Learning Board.

1 do not believe that in their own right, these steps outlined above will ensure prevention all such
incidents having tragic conclusions. | do however believe and commend to you however, that these steps
represent the Constabulary’s belief in learning and implementation of that learning drawn specifically on
these events. My hope is that once implemented we, as an organisation will be better placed to respond
to incidents such as this, in a way that will greatly enhance the chances of a different outcome.

Yours sincerely

Temporary Deputy Chief Constable

Response by Sainsbury's Supermarkets Limited to
Regulation 28 Report from HM Senior Coroner
Mrs Maria Voisin arising from the Inquest into the death
of Christopher David Taylor

1. This response to the Regulation 28 Report arising from the death of Christopher David Taylor ("the
Report") is made on behalf of Sainsbury's Supermarkets Limited ("SSL") notwithstanding the report
was addressed to Sainsbury's Plc as SSL is the legal entity which operates the store adjacent to the

River Avon in Bath. |

2. SSL was not a Property Interested Person at the Inquest nor was it invited to be so and has not had

the benefit of hearing the evidence given in the course of that Inquest.

3. SSL has been provided with a transcript of the Prevention of Further Deaths Hearing in relation to
the deaths of not only Christopher Taylor but also Samuel Amin which took place before HM Senior
Coroner Maria Voisin on the 27 November 2014.

4. The Report issued by the Coroner by letter dated 13 February 2015 was received by SSL on 16
February 2015.

5. The Coroner's Matters of Concern in relation to SSL were expressed in the following terms:

"! appreciate that Sainsbury's were not represented at the Inquest and | do not have any
evidence from them in relation to their plans for the bank next to the River Avon in Bath;
however I would ask that they consider their responsibility as land owner along this stretch of
river in question which falls within the high risk area. Specifically | would ask that they liaise

with Bath and North East Somerset Local Authority in relation to potentially the provision of a

vandal proof life buoy station along that stretch of river”.

6. SSL's response to the Coroner's concerns have been addressed in the manner set out below.

7. On 29 January 2015 (which of course precedes the issue of the Report) representatives of SSL met
with, amongst others, | the Team Manager (Licensing and Environmental
Protection) for Bath and North East Somerset Council ("the Council") and | of Avon Fire
and Rescue Services. At that meeting there was a discussion of the concerns that had arisen from
the evidence during the course of the Inquest and the subsequent evidence and representations

made at the Hearing to Prevent Further Deaths on the 27 November 2014.

8. The management of health and safety to the highest possible standards is a priority for SSL and that

approach extends to matters of public safety where we are able to work with others to enhance

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public safety and address issues of concern that have been identified such as those in this case.
Accordingly SSL has continued to work with the Council and other interested stakeholders to

address the concerns encapsulated in the Report.

9. Following the meeting on 29 January it was agreed that SSL would look at putting waist height
fencing along the upper carpark walkway area. It was decided that it would be more appropriate for
the fencing to be positioned there rather than along the actual water's edge at the bottom of the
(newly cleared) sloped bank because it was thought that putting the fencing at the pavement/carpark
level would encourage people to stay further away from the river bank. It was also considered that

there was no need for the previously heavy planted area to become accessible to passers-by.

10. The fencing to be put in place was waist height in accordance with RoSPA recommendations that full
height fencing can inhibit effective rescue of casualties in the water who may have entered the river

further up-stream.

11. Temporary Heras style fencing has been put in place and will remain until a final permanent fence

has been erected. Planning permission for the permanent fence is awaited.

12. Appropriate signage has been erected on the temporary fencing in four locations and will also be
attached to the permanent fencing. The signage is “bespoke” in design in that it encompasses a hard
hitting local message and was agreed with the Council at the meeting on 29 January 2015.

13. So far as life-saving buoys were concerned SSL had already replaced the damaged/missing buoy
referred to in evidence during the course of the Inquest. A stock of spare floats is kept at the store
as vandalism is, as recognised by the evidence given at the Inquest, a problem. The life buoys are
checked weekly as part of the store manager's normal safety routine and hence any damage will be
noted and dealt with promptly.

44. There were discussions with the Council and Avon Fire and Rescue Service as to the provision of
tamper/vandal proof buoys which are opened by callers to 999 being given a code to access the
buoys. SSL has concerns as to the suitability/practicality of such equipment. Our concern is that as
with any bespoke equipment there can be issues with maintenance and repair in the future and that
the requirement to call 999 could lead to people unsuccessfully trying to access the buoy if they did

not have a telephone and/or were in a state of panic.

15. SSL has put in place service level agreements suitable to maintaining the sloped bank area in its
current cleared/cut down state of vegetation in order to maintain the improved visibility and

emergency access that has resulted from the clearance measures undertaken.

16. SSL will keep the measures outlined above under review and if it has any reason to call into question
the validity and/or appropriateness of those measures will raise those concerns with the Council and
Avon Fire and Rescue Service. Similarly SSL will continue to work with the Council and Avon Fire

and Rescue Service and has made it plain to those organisations that should they have any future or

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on-going concerns they should raise them with SSL who will engage with them to give those

concerns proper and full consideration.

17. Finally, SSL has noted and considered the recommendations contained within the RoSPA report
referred to in the transcript of the Hearing to Prevent Further Deaths which took place before HM
Senior Coroner Maria Voisin on the 27 November 2014. In particular SSL endorses the
recommendation that the principal method of managing risk in the vicinity of the river Avon is to
educate users and potential users and SSL supports the efforts made by the Council and others in
that respect. In terms of the hierarchy of controls, which is a fundamental principle of health and
safety management, the provision of life saving equipment is a control of last resort. The key to
preventing further deaths is to prevent persons inadvertently falling into the river and the Council's

programme of information and education is integral to that.

Sainsbury's Supermarkets Limited

29 April 2015

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