Darren Neville

:
A TOTAL POLICING

DIRECTORATE OF PROFESSIONALISM

Coroner ME Hassell,

Senior Coroner, Deputy Assistant Commissioner
Inner North London St Pancras Coroner’s Court,
Camley Street Room 918
London New Scotland Yard
N1C 4PP Broadway
Tel: 0208 387 4882 London
SW1H 0BG
By Email to:

Date: 20 August 2015

Dear Ms. Hassell,

| write on behalf of the Metropolitan Police Service (MPS) in response to your Regulation
28: Prevention of Future Deaths (PFD) report dated 10" June 2015, following the inquest
touching the death on 12" March 2013 of Darren Neville. This Inquest opened before
Assistant Coroner Lynch on 9" May 2013, and concluded before you (sitting with a jury)
on the 10" June 2015, at the St Pancras Coroner’s Court.

At the conclusion of this Inquest, the jury gave a narrative determination, and you went
on to find that:

“...Mr Neville died having taken cocaine, suffering acute behavioural disturbance
and following restraint by police. His medical cause of death was:

1a cardiac arrest encephalopathy (global cerebral ischaemic hypoxia)

1b fatal dysrhythmia

1¢ restraint and struggling in association with acute behavioural
disturbance, in an individual with evidence of cocaine use (acute and
chronic.)”

The jury set out part of their narrative that:

".,.Police did not give sufficient consideration to the risks associated with
prolonged restraint to a person suffering from acute behavioural disturbance;
more specifically, the risk of death following prolonged restraint. It is unclear the
extent to which this single factor caused Darren's death."

You may recail a previous response which the MPS provided in another case (that of
Michael Sweeney who died April 2011, response delivered in November 2013) that the
MPS has in recent years invested in considerable training for officers in recognising the

medical emergency occasioned by ‘Acute Behavioural Disorder (ABD). This has been
coupled with the development of more effective joint working practices with our
colleagues in the London Ambulance Service (LAS) and the National Health Service
(NHS) when responding to such incidents.

The MPS has continued to refine and develop its response to the challenges posed by
ABD since the response provided to you in in November 2013. The MPS recognises that
dealing with ABD poses particular difficulties for officers who must balance the need to
protect an individual who be suffering from ABD from harming themselves and the need
to protect the public, against the risks inherent in restraining an individual who may be in
a state of ABD. This may of course be all the more difficult in the fast moving and
dynamic circumstances that officers are likely to encounter individuals exhibiting ABD.

| have set out below: (a) a summary of actions taken by the MPS since the conclusion of
the Sweeney inquest, (covered in greater detail in our report to you on that case);
together with (b) additional developments since the death of Mr Neville. It will be noted
that some actions set in train immediately after the verdict in Mr Sweeney’s inquest, for
example, developing the Memorandum of Understanding (MOU) between the MPS and
the LAS were still ‘works in progress’ at the time of Mr Neville’s death. This work has
now been completed as regards the joint response to any similar incidents which may
occur in the future. | should make clear that the work which | have set out below has
been carried out in consultation with subject experts in the relevant areas of police
operations and policy.

Summary of work resulting from the earlier case

One of the first improvements in the response by police and other agencies to cases of
possible ABD was the adoption of this phrase as a common terminology across first-
responding agencies to describe the behaviours which might be exhibited in individuals
with ABD. There were a number of implications for training, business processes and
practice for all parties which flowed from this.

Parts of this new approach which could be introduced rapidly were expedited. For
example, on the 3 December 2013 (a little more than a fortnight after the verdict in the
Michael Sweeney inquest) an instruction to all officers was delivered (via the MPS
intranet system), advising that from the following day, our partners in the LAS would treat
all ‘ABD’ and/or ongoing restraint calls as medical emergencies, with a target response
time of 8 minutes or less, a so-called ‘Red’ response.

Meanwhile, the MPS contribution, our intranet circulation went on to state, would be as
follows: “If a patient is being actively restrained, believed to be suffering from excited
delirium, acute behavioural disorder or cocaine toxicity, officers must ensure this
information is sent on a new CAD message to the LAS and they will upgrade to a Red
response.”

The other significant development, post the Michael Sweeney case was the publication
in January 2014 of the aforementioned MOU between the MPS and LAS to provide
guidance on joint working including use of CAD Link and Joint Response Units’. This
document sets out in detail how the respective agencies communicate about and
respond to joint incidents. It put on a formal footing the earlier ‘fast time’ agreement
(referred to above) between both agencies regarding response to ‘ABD’ and/or ongoing
restraint incidents. Governance arrangements, mechanisms for managing

disagreements over deployments, expectations of service, and so on were also
captured, and placed on a formal footing for the first time in this document.

Section 11 of the MOU, states under the heading ‘Patients being restrained or suffering
other condition’:

11.1 Physically restraining patients presents a serious risk of positional/restraint
asphyxia and death. Restraining patients with other vulnerabilities (e.g. Acute
Behavioural Disorder, under the influence of alcohol or drugs, obesity) presents
an increased risk.

11.2 MPS CAD Operators must create a new CAD and EXP/LAS clearly stating a
“patient is being restrained” in the remarks field and send this to the LAS.

11.3 The LAS will upgrade all calls where a patient is being restrained to a
RESP1 (8 minutes). This is the equivalent response code to a cardiac arrest.
Therefore the number of clinical upgrades will be closely monitored by the LAS.”

The MOU is supported by regular review meetings between the MPS and the LAS,
which were also instituted since the Michael Sweeney case and which provide an
ongoing forum for both parties to resolve any operational difficulties arising in the course
of daily business. The MOU itself meanwhile is a ‘living document’ jointly owned and
developed by both agencies through this forum, and provides a means of developing
policy on all aspects of day to day joint working. For example, at time of writing, policy
guiding the approach to the management of ‘concerns for safety’ calls (formerly known
as ‘welfare checks’) dealt with by both agencies is being developed for capture in the
next edition of the MOU.

Further developments since Mr Neville’s death

As well as the adoption of the common terminology, it was recognised that further
attention needed to be given in training and operational practice to the need for first
responders from all agencies to rapidly recognise signs and symptoms suggestive of
ABD and to then treat this as a medical emergency.

Given the size of the MPS first-responder workforce, this training had to be delivered
incrementally through the established training structure, such as the bi-annual Officer
Safety Training (OST) refresher courses, which every operational police officer up to the
rank of Superintendent is obliged to attend.

Two complementary strategies are relevant here. The first was the introduction, in
September 2013 (by the MPS Mental Health Team under the direction of Commander
Christine Jones), of the Vulnerability Assessment Framework (VAF), and it's associated
‘ABCDE’ risk-assessment tool.

The second was the practical integration of that tool into the mandatory bi-annual OST
cycle. Developed in conjunction with researchers from the University of Central
Lancashire, the VAF is intended to move officers away from earlier ‘diagnostic’ condition-
specific training regimes. The VAF acknowledges that even trained mental health
professionals often find it difficult to pinpoint the precise reason why a person may be
acting in a distressed or disordered way; and that such ‘diagnosis’ is of little direct
relevance to the range of options a police officer, as opposed to a mental health
professional, may need to consider.

The VAF provides a different approach. It encourages officers to recognise when they
are dealing with a person who is in a ‘vulnerable’ state of mind by focussing on
objectively observable behaviours and circumstances and then to adopt an incident
management style appropriate to this circumstance. ‘Vulnerability’ is defined in the
following terms in the VAF:

it] may result from an environmental or individual’s circumstance or behaviour
indicating there may be a risk to that person or another. Those who come to
notice of police as vulnerable will require an appropriate protective safeguarding
response. Additional factors to vulnerability may include mental health, disability,
age or illness and should include appropriate multi agency intervention especially
in cases of repeat victimisation.’

[Commander Jones’ Vulnerability Assessment Framework briefing note
v.2, 02/11/13]

The VAF is thus a holistic approach to assessing vulnerability and is to be utilised in all
interactions the police have with the public, regardless of whether someone is a victim,
witness or suspect. The rationale for this is that, properly used, this will pick up on any
potential vulnerability which might otherwise hamper normal communication between the
individual and attending officers, regardless of whether the difficulty is temporary of
permanent, the result of substance abuse, mental illness, or physical or mental disability.
It also offers through the use of reports into the MPS ‘Merlin’ database, a means of
developing an accessible ‘corporate memory’ over time of dealings with any individual
where ‘vulnerability’ is detected. This record may include not only a history of previous
incidents but also, where appropriate, contacts for friends, family, or mental health
professionals engaged with them, and so on.

The primary tool to aid the officer in identifying ‘vulnerability’ is the mnemonic ‘ABCDE’,
which directs the officer to consider objectively observable characteristics of the person
they are engaging with: a persons’ Appearance and _ Behaviour, — their
Capacity/Communication, any Danger their actions may cause themselves or others;
and any indications from their Environment of risk, their history of self-care, and so on.

An officer may create an ‘Adult Coming to Notice’ Merlin report for ‘vulnerability’ if any of
these elements are engaged. Where three or more elements are detected, an entry on
the database is mandatory.

Training for first responders in this new model began in January 2014, and the
underlying policy was announced formally (via the MPS intranet) on the 13" August
2014. Guidance on the approach has also been provided via ‘Policy Pages’ the 24/7
intranet ‘one stop shop’, accessible to all MPS employees. This replaces the MPS
previous approach (based upon a collection of ‘Standard Operating Procedures’) with a
series of succinct guidance documents, checklists, and Frequently Asked Questions.

Within the ‘Vulnerability and Protection of Adults at Risk Toolkit’ the relevant documents
are:

e Vulnerability and Protection of Adults at Risk Toolkit - Vulnerability
Assessment Framework (VAF) and Quick Guide Tool

e Vulnerability and Protection of Adults at Risk Toolkit - Primary Investigation -
Checklist

e Vulnerability and Protection of Adults at Risk Toolkit - Primary Investigation -
Supervisor - Checklist

e Vulnerability and Protection of Adults at Risk Toolkit - Secondary Investigation
- Checklist

e Vulnerability and Protection of Adults at Risk Toolkit - Secondary Investigation
- Supervisor - Checklist

This resource sits alongside a continuing emphasis on de-escalation tactics in the OST
sessions. The classroom element of the current cycle of the mandatory training includes
a section called ‘Mental Health - Safety In Mind’, a DVD and tutor led interactive session.
This has been developed in conjunction with South London & Maudsley Hospital (SLAM)
and the LAS and is aimed at improving the management of a situation involving a person
identified as vulnerable. This package discusses the importance of the VAF and ABCDE
models; and offers practical guidance on de-escalation tactics using the ‘CARES’ model
(see below.)

On receipt of your PFD report, PO an MPS expert on OST

related issues, has provided the following account:

“Restraint issues including ABD and Positional Asphyxia remain central tenets of
Officer Safety Training (OST), which is mandatory for all officers below the rank of
superintendent. This training is pass/fail insofar as officers must demonstrate
‘competency’ in each module of OST in order to carry out their operational duties.
Restraint issues have formed part of this training for nearly 20 years and are,
therefore, firmly embedded with continuous corporate review from local, national
and international sources. These processes, coupled with an established in-
house national secretariat and policing lead for OST, help to ensure the MPS's
commitment to the latest developments in training. These include advancement in
tactics and technologies in addition to legal, medical and ethical developments.
The current mandatory OST programme includes the following objectives:

e State the signs & symptoms of a person in crisis using the ‘Vulnerability
Assessment Framework’ (ABCDE)

e State the main causes of Acute Behavioural Disorder (ABD) and police
response

e Discuss the ‘CARES’ approach to mental illness -

Contain the situation - rather than restrain.

Approach within view of person. Avoid approaching from behind.

Reduce distractions - helmet off, turn radio down, one officer talking.
Explain what you are doing (simple language) and listen to the person.
Slow down your actions and give the person more space. Seek the help of
a relative or Carer.

REMINDER: ABD = A&E

e Where restraint is nevertheless unavoidable:
e State the role of the ‘Safety Officer’ -

Control by restraining the person.

Care by monitoring the person and being aware of the dangers of the
prone position.

Communicate with the person e.g. ‘you are under arrest’, ‘Stop resisting’.
‘We are here to help you’. Communicate also includes talking to
colleagues. If any person has any concern regarding the person’s medical
condition, it is important that they say something: ‘Speak Up/Speak Out’. If

possible have a second ‘Safety Officer’ to stand back and
observe/evidence the restraint. This can be useful as those restraining are
more likely to be affected by stress (tunnel vision etc).

e Discuss the purpose of the side control/restraint position -

To assist with breathing, monitor the person and reduce the dangers of the
positional asphyxia. This should be done ASAP. Where possible the
person should be brought to a sitting, kneeling then standing position.
Explain that in general, people are handcuffed behind their back, as it
restricts the movement of the hands. If handcuffs are applied to the front, a
person is able to move their arms around, use their elbows and grab with
their hands. However, also note/explain the comments of medical expert

with regard to handcuffing behind the back and
breathing.

Additional aspects of the current OST syllabus also include the ‘Safer Restraint’
and ‘Medical Implications of Restraint’ DVDs. These are MPS/NHS joint training
tools designed in partnership to help promote a unified response to restraint crisis
management and an enhanced understanding of each organisation’s roles and
responsibilities.

The MPS is also promoting the newly formed National Mental Health Restraint
Expert Reference Group, which is independently chaired by Lord Carlisle. This
group of leading experts from partnership groups and organisations has been
convened to help ensure a unified response to best practice across the UK. The
OST learning outcomes from such groups will continue to be fast-tracked into
corporate training as an on-going process of development, in line with College of
Policing principles. For these reasons, work is ‘on-going’ from an OST
perspective.”

Steps have also been taken at a national level to help officers structure their decision
making, in recognition of the fact that they are often obliged to make dynamic risk
assessments in fast moving situations, frequently on the basis of partial or misleading
information. This is often the position in the many emergency situations which first-
responding officers attend.

Risk taking involves judgement and balance, and harm can never be totally prevented.
Risk decisions should, therefore, be judged by the quality of the decision making, not by
the outcome. To help everyone in policing make these decisions and to provide a
framework in which the decisions can be examined and challenged, both at the time and
afterwards, the police service has adopted a single, National Decision Model (NDM),
comprised of six key elements:

e Code of Ethics — Principles and standards of professional behaviour

e Information — Gather information and intelligence

e Assessment — Assess threat and risk and develop a working strategy

e Powers and policy ~ Consider powers and policy

e Options — Identify options and contingencies

e Action and review — Take action and review what happened.

[Source: College of Policing Authorised Professional Practice website,
‘National Decision Model 15/10/14’: https://www.app.college.police.uk/app-
content/national-decision-model/ ]

The model has at its centre the Code of Ethics, as the touchstone for all decision
making. Using the model in advance of a pre-planned activity or in review after a
spontaneous incident encourages officers and staff to act in accordance with the Code,
to use their discretion where appropriate, and to evidence the thought processes behind
the actions they have taken. It also reduces risk aversion, and helps weigh the balance
of resourcing against demand, threat and risk. Police managers have undertaken to
support decision makers in instances where it can be shown that their decisions were
assessed and managed reasonably in the circumstances existing at the time even where
harm results from those decisions and actions (my emphasis). The NDM therefore
offers a way of structuring the necessary evidence to enlist that support.

Conclusion

| have not had sight of transcripts of the inquest proceedings, and make no reference
here to the particular actions of the officers involved in this incident. | have noted
however the findings of the IPCC investigation that this was “...a fast-moving, dynamic
situation” in which the first officers on scene were confronted by Mr Neville in a public
street “...dressed in only his boxer shorts and his socks... a recycling box over his head,
and he was covered in blood. When the officers went to approach...he displayed violent
behaviour towards them...” [para 290, IPCC report], with the result that the officers
moved promptly to restrain him. | understand that Mr Neville had thrown himself through
the glass window of a door and had injured himself and that this may have added to the
complexity of this situation.

The nature of behaviours associated with ABD - bizarre, often violent and erratic action,
great strength etc - frequently presents immediate risks to the person concerned,
members of the public, and to the attending first responders. ABD of itself may present
a propensity to catastrophic physiological collapse. This presents officers with an acute
difficulty because it remains the case that officers will, on occasion, be confronted by a
need to act spontaneously, and to take decisive action immediately, even if they are fully
aware of the risks involved in doing so. In short, the very factors that may indicate that
an individual is in a state of ABD may require that the individual is restrained (so as, for
example, to ensure they receive medical attention or to protect the public). Equally the
state of ABD may put the individual at significant physiological risk of collapse. Dealing
with these complexities in the sort of environment that they are likely occur has required
the MPS to refine its training (and the emphasis in that training) over the course of the
past two decades.

The MPS recognises its responsibility to furnish its officers with the equipment, tactics,
training, and cognitive tools so as to enable them to approach such fast moving,
frightening situations with confidence, and the ability to protect themselves and the
public they serve (beginning with the person before them in the incident).

| trust you will consider that the efforts we make to learn from each such regrettable
circumstance, exemplified here both by the measures introduced since 2013, and those
in response to Mr Neville’s tragic death, are evidence of our continuing commitment to
this aim.