Prevention of Future Deaths reports · 2017

Mark Banks

Regulation 28 report to prevent future deaths, reference 2017-0271, written 14 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Aug 2017
Reference2017-0271
DeceasedMark Banks
CoronerElizabeth Earland
Coroner areaExeter and Great Devon District
CategoryPolice related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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 (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Chief Constable Shaun Sawyer
Devon and Cornwall Police Headquarters
Middlemoor
Exeter
Devon
EX2 7HQ

1 CORONER

1am Dr Elizabeth Ann Earland, Senior Coroner for the Exeter and Great Devon District

2 | 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.

3 | INVESTIGATION and INQUEST

On 2" March 2015 | commenced an investigation into the death of Mark Craig BANKS,
aged 44. The investigation concluded at the end of the inquest on 13" October 2015.
The conclusion of the inquest was Alcohol Related Death.

4 | CIRCUMSTANCES OF THE DEATH

The Deceased, a long term alcoholic with mental problems, was homeless when he
suffered from exposure in an unmade tent by the Braunton side of Bradiford Water outlet
on the Tarka trail. He succumbed in the early hours of 23" February 2015 in bad
weather. Alcohol was a factor.

5 | CORONER’S CONCERNS confirmed by the unexpected, late submission (post
Inquest) of an Independent Police Complaints Commission report on 8) June

2017.

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) Failure to contact ambulance service after caller request in addition a failure to
record the request on the incident log.

(2) Failure to grade the call correctly when there was a clear danger to Mr Bank’s
life.

(3) RE: a: Page 176 of the Independent Police Complaints Commission
report — insufficient efforts to search and check upon Mr Banks’ wellbeing when
asked to attend the scene.

6 | ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and the
Devon and Cornwall Police Force have the power to take such action.

1. The Devon and Cornwall Police review its grading and deployment policy and
operational practices regarding the call grading and incident creation to ensure
that they are compliant with the National Standard for Incident Recording and
.the National Call Handling Standards, making any necessary amendments.

2. That Devon and Cornwail Police develop Standard Operating Procedure for
identifying the location of incidences which do not take place at a fixed address,
including those involving vulnerable people found in public places. This could
include prompts for call handlers to ask callers what they see around them in
different directions, whether they can provide any additional detail at all to
identify the location and whether they can attend/remain at the scene if the
location remains unclear.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 6" October 2017. I, 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.

| 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.

Date te Pi

Dr Elizabeth A Earland MB.Ch.B.,
D.A.,Dip.Law,L.P.C,Hon.LLD

HM Senior Coroner

Room 226

County Hall

Topsham Road

EXETER

Devon EX2 4QD

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 Devon Cornwall Police (PDF)
Devon & Cornwall Police

Our ref. COG/09/09/17/it
Your ref. EAE/RB File No 539-2015

Dr E A Earland

HM Senior Coroner

Room 226, County Hall

Topsham Road RECEIVED ~3 OCT 2017 Assistant Chief Constable
Exeter “ : Devon & Cornwall Police
EX2 4QD Middlemoor, Exeter

Devon EX2 7HQ

Tel. 101

2 October 2017

Dear Dr Earland,
MR MARK CRAIG BANKS (DECEASED)

| write in response to your report to prevent future deaths published under Regulation 28
of the Coroners (Investigations) Regulations 2013 regarding the death of Mr Banks. As the
Assistant Chief Constable with portfolio responsibility for demand (incorporating call
handling), | have been nominated to respond to this report’ on behalf of the Chief
Constable of the Devon and Cornwall Police (“the police”).

We are grateful to you for bringing these matters to the Chief Constable’s attention to
enable us to address them accordingly. For the avoidance of doubt, please treat this
correspondence as the Chief Constable’s response as required under Regulation 29 of
the 2013 Regulations.

For your ease of reference, | shall address each point in the ‘action should be taken’ box
of the Regulation 28 report separately.

“4. The Devon and Cornwall Police review its grading and deployment policy and
operational practices regarding the call grading and incident creation to ensure that
they are compliant with the National Standard for Incident Recording and the
National Call Handling Standards, making any necessary amendments.”

Contact the police tb
Emergency ) 999 ee 8
Non-emergency “0 www.devon-cornwall.police.uk/reportcrime Pater
101@devonandcornwall.pnn.police.uk Bey
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Follow us —@4 DevonAndCornwallPolice

‘The Government Standard
Stock code: SF615

The Force Crime and Incident Registrar is responsible for ensuring that the police are
compliant with the ‘National Standard for Incident Recording (NSIR) and for ensuring that
these standards are maintained. We have had an auditing process in place to ensure
compliance with the NSIR since 2009. Since the death of Mr Banks, we have completed
three audits, and the next is scheduled for January 2018.

In addition, since the death of Mr Banks, the police’s grading and deployment policy
(policy D051) and operational practices regarding call grading and incident creation have
been reviewed to ensure that they are compliant with the NSIR and National Call Handling
Standards (NCHS). D051 was subsequently updated to reflect that good decision-making
in terms of grading and deployment required consideration of and compliance with
national guidance on log classification; namely, the NSIR and NCHS.

The most significant change to D051 in this respect since Mr Banks’ death has been the
integration of the ‘THRIVE’ risk assessment tool (THRIVE’ standing for ‘Threat-Harm-Risk-
Investigation-Vulnerability-Engagement’). This is to prompt call handlers to consider six
elements to assist in identifying the appropriate call grading based on the needs of the
caller and the circumstances of the incident. To illustrate this further, | will briefly elaborate
on each of these elements:

e Threat: the call handler is prompted to consider who or what is in danger, where
any threat comes from, and the immediacy of any threat.

e Harm: the call handler is prompted to consider how serious any hurt or injury is,
what the value or level of any damage to property is, the extent of any harm, and
the impact on the individual(s) involved.

e Risk: the call handler is prompted to consider the probability of any threat or harm
being realised, and the impact of the police not taking. action or intending the
incident in question.

e Investigation: the call handler is prompted to consider whether they have explored
all viable opportunities to secure evidence, and whether they have fully appreciated
the impact of their actions on public confidence.

e Vulnerability: the call handler is prompted to consider whether an individual involved
in the incident is vulnerable as a result of their situation or circumstances, their
ability to take care of or protect themselves (or others) from harm or exploitation.
This section of D051 lists various points of consideration for the call handler; for
example, the family and personal circumstances of the individual(s) in question, or
the health of said individual(s).

e Engagement: finally, the call handler is prompted to consider whether they have
clearly and appropriately communicated to the individual(s) in question according to
their specific needs.

These factors are considered in their totality and are used to inform the call grading
process.

In addition, our Contact Management and Communications Unit (who are ultimately
responsible for handling incoming calls from members of the public) now have specific
staff members trained as Enhanced Crisis Communicators (ECCs). The purpose of this

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role is to provide initial contact with members of the public who are either reporting (or
otherwise indicating) intent to self-harm or potentially commit suicide. The ECCs are
specifically trained to engage with such individuals until such a time that a trained police
negotiator can be identified to assist. The ECCs are not a replacement for such police
negotiators, and are instead intended to enhance the quality of the initial contact with the
individual in question until a negotiator is available to assist. For the avoidance of doubt,
we still aim to deploy police negotiators to deal with such encounters with members of the
public as soon as possible, and the ECC is not intended to reduce the level of urgency in
doing so.

Our policy D051 is made publicly-available via our website, but | have enclosed a copy of
the most recent version for your ease of reference. You can find further detail about
‘THRIVE’ and the ECCs at paragraph 3.2.

Furthermore, as a part of our ongoing work in this area, the Registrar has directed that a
working practice should be compiled to allow for the audit of incident logs to ensure
compliance with the NSIR.

The working practice is nearing completion and | am informed that it will be completed by
the middle of October 2017. The aim of the working practice will be to explain the process
of auditing, and to define a clear process which in itself could be made available for
inspection (for example, by Her Majesty's Inspectorate of Constabulary and Fire & Rescue
Services (HMICFRS)).

The working practice will also provide for the provision of samples of incident logs to audit,
the quality assurance process, and how to compile an audit report for submissions to the
Registrar to allow them to review and offer feedback as required.

| am now satisfied that every reasonable effort has been made to ensure that the police's
policies and practices in this respect will be compliant with the required national standards.
Furthermore, in order to keep abreast of developments in this area and as a part of a
general effort to refine and improve our working practices in this regard, D051 has been
reviewed and updated on five occasions following the death of Mr Banks.

“9. That Devon and Cornwall Police develop Standard Operating Procedure for
identifying the location of incidences which do not take place at a fixed address,
including those involving vulnerable people found in public places. This could
include prompts for call handlers to ask callers what they see around them in
different directions, whether they can provide any additional detail at all to identify
the location and whether they can attend / remain at the scene if the location
remains unclear.”

Since the death of Mr Banks, the police have amended the process for assisting people
who have called us and are (for whatever reason) unable to provide their definitive
location. In these instances, the call hander now creates an incident log and refers to a
standard operating procedure which prompts them to ask the caller to confirm the
following points (where possible): .

Page 3

Their last known location;

How far they have travelled since their last known location;

What they can see at the time of the call, including the surrounding terrain;

What they can hear;

A description of themselves, including what they are wearing;

Details of their physical condition, including how they are feeling, i.e. whether they

are hungry or thirsty, or whether they are tired;

Whether they have a smartphone;

e lf they do have a smartphone, whether this is capable of downloading any
applications, whether they have a maps application, and how much battery they
have left; and

e Whether they are in a position to provide access to their smartphone (as this can

potentially allow the police to identify their location via GPS technology, and in a

manner that does not require the caller to remain connected, thus preserving their

battery life).

The standard operating procedure also prompts the call handler to consider policy D051,
complete research and check records where appropriate (for example, by reviewing the
Police National Computer or identifying any information required by any police officers
attempting to locate the individual). It also reminds the call handler to reassure the caller
by explaining to them how the police will respond and what will happen.

1 am also pleased to be able to report that during the fast Police Effectiveness, Efficiency
and Legitimacy (‘PEEL’) assessment undertaken by Her Majesty’s Inspectorate of
Constabularies (now HMICFRS) in Autumn 2016, the police were assessed as having a
“good” management of vulnerability. Their report in this area described our approach
towards vulnerability as follows:

“Devon and Comwalil Police is good at protecting those who are vulnerable from harm and
supporting victims. It defines vulnerability clearly and there is a good understanding
among officers and staff. Assessments for risk and vulnerability are evident in all parts of
the force and they guide the police response. There are appropriate structures and
governance in place. The force understands the risks it is dealing with.”

In relation to the police’s call handers, the following comments from the report may also
provide some reassurance:

“The level of understanding of THRIVE by control room staff is good and we found they
obtained and graded information correctly on a consistent basis. Staff can access a range
of systems to search for the information and intelligence they need to make a considered
deployment decision.”

| believe that this reflects positively on the work and changes undertaken by the police in
this area.

We believe that each of the areas of concern identified within the Regulation 28 report
have now been addressed, and | hope that this explanation serves to reassure you that a

Page 4

number of significant steps to improve our performance in this regard have been taken
following Mr Banks’ death. However if you do have any outstanding concerns on these
issues, please do advise and | would be happy to revisit the matter if necessary.

For the further avoidance of doubt, we can confirm that we have no objections to this
response being provided to the family of Mr Banks or any other interested parties in this

matter. Should you require any further information in relation to any of the identified areas
then please do contact us again accordingly.

Yours sincerely
FT

Assistant Chief Constable

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