Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0355, written 11 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Oct 2016 |
|---|---|
| Reference | 2016-0355 |
| Deceased | Tyrone Lock |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
THIS REPORT IS BEING SENT TO:
1. Chief Constable Anthony Bangham
West Mercia Police Headquarters
Hindlip Hall
PO Box 55
Worcester
WR3 8SP
2. Chief Superintendent Tyron Joyce
National Police Air Service
West Yorkshire Police
PO Box 9
Wakefield WF1 3QP
CORONER
1am John Ellery, Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin
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
On the 25‘ November 2015 | commenced an investigation into the death of Tyrone
Ashley Lock, 18 years of age, who was found deceased in a pond at the Macdonald Hill
Valley Hotel, Golf & Spa on the morning of Monday 23"? November 2015.
The inquest, with a jury, commenced on the 3 October 2016 and concluded on the 6"
October 2016. The jury recorded a narrative conclusion identifying police failings
contributing to Tyrone’s death.
CIRCUMSTANCES OF THE DEATH
Tyrone and 2 friends checked in to the Hill Valley Hotel on Friday 20° November 2015.
During the night and early morning of Saturday 21%* November 2015 there were
disturbances which resulted in the police being called. On their arrival the police saw a
male get out of and run away from a van which he had been driving. A request for a
police helicopter was made in respect of that male, namely a suspected drink driver
making off on foot with no aggravating features. The limited flying time available did
not make a deployment viable. During this time Tyrone and his female friend were still
inside the hotel and were in the main reception area as seen on the hotel CCTV.
Following their contact with the male who had run away the officers then entered the
hotel. At that time Tyrone and the female were inside a hotel lift. When they came out
one officer primarily dealt with the female and the other sought to engage with Tyrone.
Without being able to do so Tyrone ran out of the hotel wearing boxer shorts and socks
only. It was cold night, approximately 4 degrees centigrade, it was windy. A police dog
unit attempted to find Tyrone but without success. He had been classified by the police
as an absconder, not as a vulnerable person and second request for a helicopter was
not made. He was found 2 days later on the 234 November 2015 in a pond between the
16" and 18" fairways.
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 jury concluded that Tyrone should have been assessed differently from the first
male and should have been classified as a vulnerable person and not as a suspect that
was absconding.
(2) The jury believed that a second request for a helicopter should have been issued
and that it would have been deployed and that in this case there would have been a
chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what
was said to them by the night manager and from their own observations that Tyrone’s
departure could be described as “hallucinating, foaming/frothing at the mouth, spaced
out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks
only. It was very cold, 4 degrees, it was windy and he ran out into open ground with
water courses with somebody out to get him and on the police log according to the
night manager an ambulance probably would be a good idea.” It was on this evidence
that the jury concluded that Tyrone should have been classified as a vulnerable person,
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed
that they would have classified Tyrone as a vulnerable person and would have made
every effort to deploy a helicopter to the scene. NPAS further indicated that because
one request in the same incident had met with a refusal that did not mean a second
request would also be refused. Each request would be dealt with on its own merits.
Here a second call would have been treated as a top priority job. NPAS would not be
concerned with why someone was running away from the police, their concern would
be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that,
regardless of Tyrone’s status, a second call to NPAS would have met with the same
result and there would be no point in making such a request. Further two duty
sergeants involved on the Saturday and Monday mornings had different views as to
what risk of harm meant. One thought it meant risk of suicide only, the other that it
would extend to non-fatal or accidental harm.
{6) As NPAS serves all police forces in England and Wales they are included in this
report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to
what one may expect of the other.
b. To review whether any other police force may also have a similar lack of
understanding.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you 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 8" December 2016. |, 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. — Solicitors for Mr Steven Lock, father of deceased
2. mother of deceased
3. ERE Solicitor for the chief Constable
| 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
Coroner.
rnin
J.PMéller
Senior Coroner
13" October 2016
2 responses 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.
West Yorkshire Police Headquarters PO Box 9 Wakefield WF1 3QP www.npas.police.uk National! Police Air Service JP Ellery Senior Coroner for Shropshire, Telford & Wrekin H.M Coroner’s Service Shirehall Abbey Foregate Shrewsbury Shropshire SY2 6ND 13 October 2016 Dear Mr Ellery Tyrone Ashley Lock Deceased Thank you for letter received today that included a Regulation 28 report following the death of Mr Tyrone Locke. | am aware that Insp Hepworth my Operations Centre Manager has been working alongside local staff and your office to provide information and testimony. | feel that it may be useful at this time to update you on our efforts to assist learning from this tragic event at both a local level with West Mercia Police and across England and Wales. Ee NPAS Assistant Operations Director for this Region has already contact Mercia Police to support them in a Critical Incident debrief for this tragic event. will offer his opinion, supported by my Senior Leadership Team of any improvements in awareness or training that may further benefit the force. On Friday 14 October | am attending the NPAS Independent Assurance Group. In brief this is part of our governance structure and represents six Assistant Chief Constables who represent the Regions of England Wales and is also attended by Chief Constable Simon Byrne the National Police Chief Aviation lead. | will discuss this matter with them and seek their assurance that they are testing the processes and procedures within their Region This matter will also be reported upon to the NPAS Local Strategic Board for further consideration. This Board is attended by the Chief Constable and Police and Crime Commissioner for West Yorkshire Police. They will consider what, if any further action is required to share the potential lessons learned in this case. Should you require any further detail, please do not hesitate to contact me directly. Yours sincerely Chief Operating Officer
POLICE NON-EMERGENCY ho West Mercia POLICE Anthony Bangham Chief Constable West Mercia Police Headquarters, Hindlip Hall 25 NOV 2016 PO Box 55, Worcester WR3 8SP Direct Dial: Mr J P Ellery Senior Coroner HM Coroner's Service Shirehall, Abbey Foregate Shrewsbury Shropshire SY2 6ND 18 November 2016 Dear Mr Ellery Response to Regulation 28 Report into Tyrone Ashley Lock Jury Inquest: 3-6 October 2016 | have read the regulation notice dated 13" October 2016 pertaining to the above inquest and have noted the six points of concern that you have identified. | respond to each one separately as follows. Point 1 Tyrone should have been treated as a vulnerable person and not a suspect. Response 1 This point is accepted. | can confirm that in terms of supporting officers and staff West Mercia Police has already embarked on an extensive programme of work to raise awareness and understanding of vulnerability. We are keen that our people are professionally curious and recognise where those who cannot help themselves may require our help, support and intervention. We are finalising a vulnerability strategy which includes national effective practice. q INAN EMERGENCY CALL 999 www.westmercia. police.uk @wmerciapolice west mercia police We have piloted a programme within the Telford area which encourages officers and staff to see beyond the obvious and think wider. This will be rolled out across West Mercia in 2017. The use of the National Decision Making Model (NDM) is embedded across West Mercia. The NDM has six key elements. Each provides frontline officers and staff with an area for focus and consideration and can be applied to a range of circumstances. We have complemented the NDM by introducing the THRIVE model, (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) across the Force. NDM and THRIVE both provide a framework for officers and staff to seek out as much information that they can and make sound rational decisions to protect the public. To increase our professionalism further, officers and staff have been provided with an ongoing programme of development built around protecting people from harm. Officers and staff with specialist knowledge have provided training across the 13 strands of public protection, including high harm areas such as mental health and missing persons. These sessions are also supported by an extensive programme of on-line learning and knowledge checks provided by the College of Policing. Clearly every incident reported to the Police will be assessed on its own merits. However such an extensive programme of ongoing work will ensure that going forward, officers and staff will be better placed to identify and manage vulnerability and ultimately protect the public we serve. Point 2 That a second call to request the services of the helicopter should have been issued. Response 2 This point is accepted. Throughout the investigation into Tyrone’s death, there has been extensive consultation with colleagues in NPAS in order that we better understand the NPAS call out procedure and ensure that this is clearly articulated to operational officers and staff. Following the inquest T/ACC Cullen chaired a Critical incident Management Meeting which was attended by senior colleagues from NPAS. NPAS have subsequently written to all 44 police forces in England and Wales a briefing document on the policy and procedure for the deployment of NPAS aircraft. This includes the key point that when a request is declined that decision will remain under review and it should not be assumed a second request will also be declined. Further, in consultation with NPAS, we have ensured that where attendance is declined, a fuller explanation setting out the reasons for non attendance is provided. This additional information will assist officers on the ground to review the information they have, to re- assess whether another request may be necessary. This was an important aspect of this particular case and | am satisfied that this change in procedure will help to ensure that further secondary requests for air support are always considered in the future. Point 3 Collectively there was information available to the police at the time that led the jury to conclude that Tyrone should have been classified as a vulnerable person. Response 3 This is accepted and as outlined in response 1, West Mercia has embarked on an ambitious programme to enhance vulnerability training for all staff and officers across the organisation to ensure such situations do not occur in the future. Point 4 That NPAS have stated that had they received a second call to attend following Tyrone running off from officers, they would have made every effort to attend. Response 4 As outlined in response 2, it is accepted that officers on the ground should have considered that a second call to NPAS be made. | have set out in response 2 what actions we have already taken in consultation with NPAS to ensure that officers are aware of the call out procedures for, and capability of, NPAS so that similar circumstances may be prevented in the future. Point 5 This point includes two separate issues.- i) Contrary te NPAS evidence the police officers concerned believed that regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. ii) Two duty Sergeants involved on the Saturday and Monday had different views as to what risk of harm meant. Response 5 i) As outlined in responses 2 and 4, all officers have now received clear and concise guidance relating to NPAS call out procedures and capability. ii) Clearly the situation had developed over time and the Sergeant who managed the incident on a Saturday morning was acting upon different information and was under a different belief than the Sergeant who recovered Tyrone’s body on the Monday morning. Whilst policing by its very nature will always be dynamic our investment in developing officers and staff is designed to promote consistency and ensure such situations are avoided in the future. Point 6 This point includes two separate issues:- a) NPAS are included in this report so that liaison may take place between the two organisations b) NPAS are to review whether any other police force may also have a similar lack of understanding | | Response 6 a) As outlined in response 2, West Mercia Police has already undertaken extensive liaison with NPAS in relation to this case and the learning points emanating from it, for both organisations. b) | understand that NPAS are actioning this point separately and have responded to you directly. / | am satisfied that with the extensive programme of vulnerability training already underway, coupled with the ongoing improvements already put in place with NPAS colleagues, the force has done all it can to prevent such a circumstance arising again. | trust that the above response demonstrates how seriously the force has taken the learning from this tragic incident, and answers your concerns in relation to the matters raised. Yours sincerely Ae aw (ke — ey Anthony Bangham Chief Constable
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