Prevention of Future Deaths reports · 2017
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 report | 14 Aug 2017 |
|---|---|
| Reference | 2017-0271 |
| Deceased | Mark Banks |
| Coroner | Elizabeth Earland |
| Coroner area | Exeter and Great Devon District |
| 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 (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
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.
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 = Vu | 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 Page 2 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 NOTE: We are not prepared to accefpt service of documents by electronic mail OJ / 007884 / 617569 Joint Legal Services for Devon and Cornwall Police and Dorset Police gather and hold personal data. This may be shared where necessary with third parties acting for and on behalf of the Chief Constable. Personal data is processed securely at all times and is held no longer than is necessary. The retention period is six years in accordance with the Limitation Act 1980. Retention can be longer on a case by case basis where this is necessary and in accordance with the Management of Police Information (MoPI).” If you wish to know more about how we process personal data please do visit our respective websites at: hitps:/Avww.devon-cornwall.police.uk/your-right-to-information/data-protection-requests/privacy-noticefair-processing/ Page 5
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