Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0325, written 24 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jul 2017 |
|---|---|
| Reference | 2017-0325 |
| Deceased | Richard Davies |
| Coroner | Nicholas Moss |
| Coroner area | Cambridgeshire and Peterborough |
| 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
THIS REPORT IS BEING SENT TO:
1. The National Police Chiefs’ Council, (Deputy Chief Constable Simon
Chesterman QPM, National Armed Policing Working Group)
2. The Chief Constable of Bedfordshire Police (Chief Constable Jon Boutcher
QPM) as the responsible officer for the joint Armed Policing Unit for
Bedfordshire, Cambridgeshire and Hertfordshire police forces.
CORONER
| am Nicholas Moss, Assistant Coroner for the coroner area of Cambridgeshire and
Peterborough.
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 22 October 2015, an investigation was commenced into the death of RICHARD
THOMAS DAVIES, AGED 41. The investigation concluded at the end of an inquest with
a jury on 21 July 2017. The medical cause of death was 1a gunshot would to the chest.
The narrative conclusion of the jury in answering a questionnaire was:
« Richard Davies died as a result of a single round fired by a police firearms
officer;
e Lawful killing;
e Richard Davies acted in a way that was intended by him to get the police to
shoot him;
« The jury did not find there to be any errors or omissions in relation to the police
communications or negotiation attempts which were possible causes of the
death. However, they recorded that they were uncomfortable that telephone
negotiations were not considered as although there was only a low possibility it
would have affected the outcome, it was worth pursuing.
CIRCUMSTANCES OF THE DEATH
Following a number of developing personal and health problems, on 21 October 2015
Mr Davies threatened his children with a knife and tied them up in the family home. The
police were called. Six Armed Response Vehicle firearms officers from the Bedfordshire,
Cambridgeshire and Hertfordshire Police Armed Policing Unit responded. Upon their
attendance at the scene, a number of rounds were fired by Mr Davies from a homemade
firearm using live .22” ammunition. After four shots by Mr Davies, one of the firearms
officers fired a single round from his police-issue Heckler & Koch G36 carbine almost
simultaneously with a fifth shot fired by Mr Davies. Mr Davies was killed by the police
shot.
The bullet which hit and killed Mr Davies fragmented in his body. There was no exit
wound. The bullet track went through Mr Davies’ left clavicle destroying the medial third
of that bone. Fractured bone pieces and/or the fragmented bullet pieces caused
significant damage to the subclavian artery which was the most immediately fatal of Mr
Davies' multiple injuries.
On the evidence heard at the inquest, and given the significant bullet-strike on bone and
bone fragmentation, | determined that there was insufficient evidence (and it would be
unduly speculative) to conclude that the unbonded construction of the bullet used by the
Armed Policing Unit was a possible cause of this death. Accordingly, | ruled that this
issue would not be left to the jury.
Nevertheless, the use by this joint Armed Policing Unit of unbonded ammunition gives
rise to the concerns addressed below.
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 could occur unless action is taken. In the
circumstances it is my statutory duly to report to you.
The MATTERS OF CONCERN are as follows. —
Use of unbonded ammunition by Bedfordshire, Cambridgeshire and Hertfordshire
Police.
4. The joint Armed Policing Unit (APU) of Bedfordshire, Cambridgeshire and
Hertfordshire (BCH) Police issued their firearms officers with a type of 5.56mm
jacketed soft point ammunition which was unbonded (the lead core of the bullets
was not chemically treated to bind it to the bullet jacket). It is likely that this type
of ammunition was compliant with (now historic) guidance on police ammunition
issued in 1988. However, it was not the ammunition contained in (non-binding)
recommendations by the Association of Chief Police Officers (ACPO) since
December 2005. The Inquest heard that this ammunition had been used by
BCH for very many years, was used at the date of Mr Davies’ death in October
2015, and continued to be used until fast month, June 2017.
The National Position: the use of specified bonded ammunition is recommended
but not mandated; no bullet mass retention specification issued
2. In 2005 and again in 2012, the Association of Chief Police Officers (ACPO)
issued ammunition recommendations to police force firearms leads. For 5.56mm
ammunition, the ammunition that was recommended was the Federal 62 grain
Tactical Bonded round (2005) to which was added, as an alternative, the
Federal 55 grain Tactical Bonded round (2012). These are both bonded
jacketed soft point bullets.
3. The selection of this limited number of recommended types of ammunition (both
of a bonded construction) from 2005 followed ballistics studies carried out on
behalf of the Nordic police forces in 2004. The UK Home Office Police Scientific
Development Branch (PSDB) contributed to the Nordic specification and studies
because many of the requirements of the Nordic countries were shared by
police forces in the UK. The Nordic studies identified that several kinds of
ammunition tested were considered to cause unjustifiable and excessive injuries
due to their propensity to fragment after impact on test firing into a muscle-tissue
simulant.
4. The inquest evidence suggested that the selection by ACPO (on the basis of
PSDB advice) of bonded jacketed soft point ammunition following these Nordic
studies was due to a combination of two features. First, their favourable
operational performance characteristics for police use (including retaining their
effectiveness and stopping power when shot through glass). Second, the fact
that they did not show the concerning fragmentation risks identified in some
other rounds during the Nordic studies. In particular, a PSDB letter to ACPO
dated 13 July 2005, having identified the desirability of the Federal 62 grain
Tactical Bonded round, stated “Some of the other rounds tested [in the Nordic
Studies] exhibited undesirable characteristics, particularly excessive
fragmentation, that might call into question their continued use by some
forces” (emphasis added). The particular unbonded ammunition used by BCH
was not tested in the Nordic studies.
11.
Correspondence dating back to 2005 shows that ACPO/PSDB were on the brink
of issuing a new performance specification for 5.56 mm ammunition in the
summer of 2005: “We are ...nearing completion of trials to evaluate 5.56 ...mm
ammunition and publish performance specifications for these calibres for the
first time” (26 May 2005); “The next stage of the process is to finalise the
performance specifications. This will be carried out over the summer, with the
intention of having them available by the end [of] September” (13 July 2005).
Such specifications would presumably have drawn heavily on the Nordic
specification and studies, including avoiding the risk of unnecessary injuries
from excessive bullet fragmentation.
For reasons which remained unclear at the inquest, no such performance
specification was issued, whether in 2005 or since. Instead, the (non-binding)
ACPO recommendation for the use of the Federal 62 grain Tactical Bonded
round was issued on 20 December 2005. Thereafter, while ACPO/PSDB
recommended the use of this specified bonded ammunition, police forces were
not mandated to use them and could instead opt to use alternative ammunition
of their own choice.
In 2009, the Metropolitan Police Service issued an ammunition specification
which did draw on the Nordic specification and studies. It included a scoring
system for the percentage of bullet mass retained following impact, which
favoured bullets which are less likely to fragment. However, the inquest heard
that this specification was not adopted nationally, and indeed Bedfordshire
Police were apparently unaware of its existence until this inquest.
During the course of this coronial investigation, it was made clear to me that
neither the Metropolitan Police nor CAST (the Home Office Centre for Applied
Science and Technology, successor to PSDB) had ever tested the type of
unbonded ammunition being used by the APU of BCH Police.
In May — June 2012, there was an exchange of emails between the Chief
Firearms Instructor of Bedfordshire Police and a Senior Scientific Officer of
CAST. The email sought confirmation that the unbonded round being used by
BCH was “still suitable’. | was told in evidence by the Senior Scientific Officer
that his reply was not meant to convey any approval for BCH's continued use of
the unbonded ammunition. However, it appears that the Chief Firearms
Instructor of the APU did not interpret the response in this way. The evidence
heard at the inquest suggests that there was a misunderstanding in this
exchange and a missed opportunity to consider the appropriateness of the
unbonded ammunition being used by the APU of BCH.
. The Authorised Police Practice on Armed Policing (2013) makes clear that:
« CAST has published guidance in respect of ammunition (an apparent
reference to the ACPO recommendations of 2005 and 2012 which was
based on PSDB/CAST advice);
¢ Only ammunition subject to strict factory quality control should be issued
for operational purposes;
e “Where forces choose a calibre or bullet configuration that has not been
assessed by CAST to ACPO operational requirement, the ammunition
must comply with international conventions and any policy issued by
ACPO. In addition forces must be satisfied that the ammunition functions
correctly in the weapon issued and that the ballistic performance of the
ammunition meets operational requirements.” (emphasis added)
The evidence called at the inquest suggested that no policy had in fact been
issued by ACPO or CAST to cover ammunition specifications in the event that
police forces opted not to adopt the bonded JSP ammunition recommended by
ACPOICAST. Accordingly, the evidence suggested that there was no nationally |
12.
13.
available policy or specification which would guard against the risk of excessive
injury through bullet fragmentation in the event that forces did not adopt the non-
binding recommendation to use one of the two bonded 5.56 mm rounds.
Specifically, evidence from Bedfordshire police suggested that the Nordic
specification had included a requirement that the bullet shall retain at least 93%
of its weight when shot with a long reference weapon at 10 m into a 20x20x25
cm block of defined 10% ballistic gelatine. The inquest received no evidence to
suggest that this 93% threshold had been adopted as a national requirement for
ammunition for police forces in England in Wales despite the Nordic report that
several bullet types tested were considered to cause unjustifiable and excessive
injuries due to their propensity to fragment.
Accordingly, as of today’s date, | have received no evidence to suggest
that the risk of excessive injury from bullet fragmentation identified in the
2004 Nordic studies has been addressed for police forces in England and
Wales other than by a recommendation for the use of two types of bonded
5.56mm ammunition, in circumstances where that recommendation is not
binding on police forces. The risk of excessive injury from bullet
fragmentation is not addressed in the ammunition section of the
Authorised Police Practice on Armed Policing and there appears to be no
national specification for 5.56 mm ammunition which police forces can
apply if (for whatever reason) they do not adopt the non-binding
recommendations to use either the Federal 62 grain Tactical Bonded
round or the Federal 55 grain Tactical Bonded round.
The Local Police Force Position
14,
15.
16.
The current Deputy Chief Constable responsible for the Armed Policing Unit for
Bedfordshire, Cambridge and Hertfordshire police gave evidence to the inquest
to seek to explain the reasoning for that unit using the unbonded ammunition
rather that the ACPO/CAST recommended bonded ammunition. | also received
evidence from the former Chief Firearms Instructor of the Armed Policing Unit.
The Deputy Chief Constable recognised that the Force had experienced
difficulty in retrieving the audit trail of decisions historically on why these three
police forces had chosen particular ammunition.
Of concern were the following matters:
(1)A report prepared for the purpose of the inquest and adopted by the
Deputy Chief Constable set out the background without any reference at
all to the ACPO circular of 2005 which had recommended the Federal 62
grain Tactical Bonded round;
(2) The report sought to maintain that the guidance issued by ACPO in 2012
did not supersede previous lists of ammunition. In fact, the 2005 circular
had stated in terms that “Forces should be aware that these are currently
the only two products to meet the new performance specifications”,
(3) The report sought to rely upon a tender process that had been ongoing in
2005 when a different police force leading the tender had corresponded
with the Home Office’s PSDB. While it is right that at that stage the Home
Office advised that the previous (1988) guidance could be followed for this
tender, the report from Bedfordshire police failed to acknowledge that the
Home Office had cautioned in May 2005 that “It may be prudent to
consider your needs for the next 6-12 months as any changes are likely to
be introduced during this period”. The report further omitted to mention
that seven months later, in December 2005, ACPO issued the guidance
recommending the Federal 62 grain Tactical Bonded round;
(4) The report suggested that minutes of an ACPO meeting dated 24 May
2012 evidences that the police forces and officers present raised concerns
regarding the over penetration of the recommended bonded ammunition.
The Deputy Chief Constable accepted in evidence that, in fact, based on
the relevant minutes, that meeting had appeared only to consider the
relative performance of the two bonded ammunition types recommended
by ACPO;
(5) BCH police relied upon the fact that in 2012, the ammunition being used
by the APU was tested as part of a new tendering process. As part of that
testing, the ammunition met a series of technical specifications for
ammunition quality. However {in the continuing absence of any
ACPOI/CAST specification and any standard for bullet mass retention),
there was no evidence to suggest that this testing had applied the 93%
Nordic standard (or indeed any particular standard) for bullet mass
retention;
(6) The exchange of emails with CAST in 2012 appears to have been
interpreted by BCH as confirmation that the unbonded ammunition it was
using was still suitable. The evidence suggested that this was not CAST's
intention. Making allowance for the possible misunderstanding in this
exchange of emails, there was nevertheless no evidence available to this
inquest to suggest that those responsible for ammunition within the APU of
BCH were aware of (or had applied their minds to) the risks of excessive
injury through ammunition fragmentation, as identified in the Nordic
studies, at any time prior to June 2017 when it arose in the course of this
inquest.
(7) The BCH report prepared for this inquest and produced on 9 July 2017
relied on manufacturer's data (indicating a bullet mass retention of 92% at
10 yards) and appeared to suggest that this was close enough to the
Nordic standard of 93% at 10 metres to aver that the Nordic standard had
been met. At least on the evidence produced to the inquest, this was the
first time that consideration had been given to the bullet fragmentation
risks of the ammunition being used by the APU of BCH police.
17. Accordingly, | am concerned that the Armed Policing Unit of Bedfordshire,
Cambridgeshire and Hertfordshire police forces:
¢ Is or may be treating NPCC (previously ACPO)/CAST ammunition
recommendations as not superseding previous recommendations
contrary to the wording of those recommendations.
« Does not have in place a system to ensure that if NPCC/CAST
recommendations on ammunition are not followed, the
ammunition it adopts avoids the risk of excessive / unnecessary
injury identified in the Nordic studies.
¢ Has not retained proper records of decisions made in respect of
operational ammunition when it has decided in the past not to
follow non-binding national guidance.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you AND/OR
your organisation 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 Monday 18 September 2017. |, the Assistant 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
1 have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
(1) Members of Mr Davies’ family c/o Matthew Gold & Co Solicitors;
(2) The Chief Constable of Cambridgeshire Police c/o Weightmans Solicitors;
(3) The Independent Police Complaints Commission.
| have also provided copies for information to the Police and Crime Commissioners for
Bedfordshire Police and Cambridgeshire Police.
{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.
24 July 2017 Nik, Mid
Nicholas Moss
Assistant Coroner
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 TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
ON BEHALF OF THE CHIEF CONSTABLE OF BEDFORDSHIRE POLICE
Introduction
1.
2.
3.
This response is provided on behalf of the Chief Constable of Bedfordshire Police to
the report to prevent future deaths1 dated 24 July 2017 made by Assistant Coroner for
Cambridgeshire and Peterborough, Nicholas Moss, following the inquest touching the
death of Richard Thomas Davies on 21 October 2015 in St Neots, Cambridgeshire.
The Chief Constable of Bedfordshire Police provides this response in his capacity as
the Chief Constable of the lead force for the collaborated joint Armed Policing Unit
(APU) for the police forces of Bedfordshire, Cambridgeshire and Hertfordshire (BCH).
Since 2012, the APU has been part of a collaboration of services across the tri-force
area, encompassing armed response and major crime units, collectively known as the
Joint Protective Services (JPS). Bedfordshire Police is currently the strategic lead for
firearms within the tri-force area.
Relevant background
4.
5.
6.
Firearms officers from the BCH APU attended Mr Davies’ home address on 21 October
2015. After several rounds fired by Mr Davies, one of the firearms officers fired a
single fatal round from a police-issue Heckler & Koch G36 carbine. The bullet used
was “un-bonded”2 55 grain
jacketed soft point (JSP) 5.56mm ammunition
manufactured by an American company called Federal.
The inquest revealed that this un-bonded type of ammunition was not one of the two
types of 5.56mm ammunition recommended for police use by the Association of Chief
Police Officers (ACPO) in national circulars dated 20 December 2005 and 4 May 2012.3
The ACPO recommendations, which were not mandatory or binding on police forces,
were based on advice provided by the Home Office Centre for Applied Science and
Technology (CAST) and its predecessor, PSDB.4 In July 2005 PSDB advised ACPO of
ballistics studies conducted by Nordic police forces in 2004, which had shown that
1 Under paragraph 7 of Schedule 5 to the Coroners & Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013.
2 Meaning the lead core of the bullet is not chemically bonded to the bullet jacket.
3 The Federal 62 grain tactical bonded round was recommended in 2005; the Federal 55 grain tactical bonded
round was added as an alternative in 2012.
4 Home Office Police Scientific Development Branch (PSDB) also known as the Home Office Scientific
Development Branch (HOSDB).
1
7.
8.
9.
bonded JSP 5.56mm ammunition did not carry the risk of excessive fragmentation
identified in other (rejected) rounds.5
The results of the Nordic testing led to the inclusion of the ammunition recommended
in the December 2005 ACPO circular (62 grain tactical bonded). In 2009 the
Metropolitan Police Service (MPS) produced a specification for 5.56mm ammunition,
which led to the inclusion of the ammunition recommended in the May 2012 ACPO
circular (55 grain tactical bonded). The MPS specification was never adopted
nationally or distributed to the BCH APU.
Both of the ammunition types recommended by ACPO in 2005 and 2012 were bonded
JSP bullets (they were also manufactured by Federal).6 The un-bonded bullet used by
the BCH APU was not one of the rounds tested as part of the Nordic studies, nor has it
ever been tested by PSDB/CAST (or the MPS).
In May 2012 a request was made by the Chief Firearms Instructor within the BCH APU,
to the Senior Scientific Officer at CAST, as to the continued suitability of the un-
bonded ammunition being used by the APU. Unfortunately the response from CAST,
if it was intended not to convey approval for BCH’s continued use of the un-bonded
ammunition (which was not stated explicitly), was misinterpreted by the Chief
Firearms Officer, who understood that CAST had recommended its use.7
10. The Authorised Professional Practice on Armed Policing (APP-AP), which was issued by
the College of Policing8 in 2013 and remains in place, states:
“Details in respect of ammunition configuration are contained within CAST
publications. Bullet configuration is designed to address issues associated with the
penetrative qualities of the ammunition as well as minimising the potential of
ricochet and over penetration.
Where forces choose a calibre or bullet configuration that has not been assessed
by CAST to ACPO operational requirement, the ammunition must comply with
international conventions and any policy issued by ACPO. In addition, forces must
be satisfied that the ammunition functions correctly in the weapon issued and that
the ballistic performance of the ammunition meets operational requirements.”9
(emphasis added)
11.
In 2015 ACPO was replaced by the National Police Chiefs’ Council (NPCC).
5 PDSB letter to ACPO dated 13 July 2005.
6 See footnote 3.
7 As explained in paragraph 9 of the Coroner’s Reg. 28 report.
8 The body responsible for issuing guidance, in the form of APP, on professional practice in policing.
9 Paragraph 2.4 of the APP-AP: Ammunition configuration.
2
12. On 28 July 2017, in response to the Coroner’s Reg. 28 report, the NPCC issued a
circular stating that guidance on the evaluation and approval of ammunition for police
use is to be found in:
i.
The Home Office Code of Practice on the Police Use of Firearms and Less Lethal
Weapons 2003. This does not contain any guidance on the use or approval of
ammunition, although according to the NPCC circular the Code of Practice is in
the process of being revised and “will include further advice on the process for
the evaluation of weapons and ammunition”;
ii. The APP-AP, as set out at paragraph 10 above; and
iii. The advice published by CAST, most recently contained in the May 2012 ACPO
circular.
13. The July 2017 NPCC circular further stated (emphasis added):
“Current procurement arrangements and capacity mean that it is not feasible for
CAST to evaluate every type of ammunition available from manufacturers. The
ammunition included in the recommendations is therefore not definitive or
exclusive. Where a force decides to adopt ammunition for operational use which
is not included on the circular, the guidance below, provided by APP–AP, should
be complied with.
[extract from APP-AP as outlined in paragraph 10 above]
The key operational requirements identified by the police service are that the
operational ammunition;
• complies with the Hague Conventions (1899 and 1907). The fundamental
principle being to avoid …“the employment of arms, projectiles or material
calculated to cause unnecessary suffering…”
• has the ability to stop a threat with a minimum number of rounds. For this
reason the ammunition should deliver most of its energy within the subject
and not over penetrate
• should be capable of penetrating car body work, glazing, wooden doors and
panels. An ability to penetrate commercially available body armour would
also be an advantage
• has an effective range of about 2 – 100 metres.
Where a force is using, or considering adopting, ammunition that is not included
on the 2012 recommended list, the force must be satisfied that the ammunition
meets the operational requirement. This requires that the ammunition meets or
exceeds the requirements outlined above, identified within the police service
3
operational requirement, and the performance of ammunition listed in the
national circular 12/2012.
Any decision to approve ammunition for operational use other than in
accordance with this guidance must be documented and justified on the basis of
a threat and risk assessment.”
14. As the Coroner has noted, no national policy or performance specification has been
issued for 5.56mm ammunition – by ACPO, the NPCC or CAST – since the last, non-
binding ACPO recommendation in May 2012.10
15. CAST has not issued any advice in relation to the 2004 Nordic studies since the advice
offered by its predecessor (PDSB) to ACPO in July 2005.
Response
16. Following the most recent tender process in 2017, the BCH APU has, in conjunction
with the Eastern Region Armed Policing area,11 moved to using the 55 grain tactical
bonded version of the 5.56 ammunition, as recommended in the May 2012 ACPO
circular, for all operational purposes. The BCH APU is no longer using un-bonded
5.56mm 55 grain JSP ammunition operationally.
17. Decisions relating to the use of ammunition by the BCH APU are taken by the Firearms
Steering Group (FSG), which is chaired by Paul Fullwood, the Assistant Chief Constable
(ACC) for Joint Protective Services (JPS). In attendance at the FSG are the Chief
Superintendent Commands for Bedfordshire, Cambridgeshire and Hertfordshire, the
JPS trainer, the Uniformed JPS Superintendent and the JPS Staff Officer. Each force
has its own firearms user group which raises issues for discussion by the FSG.
18. The FSG meets every three months. Any policy decisions taken by the FSG are
recorded in a report, which is sent to the Board of the JPS for approval. The minutes
of FSG meetings and any reports submitted to the JPS Board (and/or any minutes of
JPS Board meetings) are recorded on a local computer system called “OneNote”.
19. The BCH APU is also required to produce an annual Strategic Threat and Risk
Assessment (STRA), the purpose of which is to establish the operational requirements
for the use of firearms and less lethal options within the tri-force area and to enable
decisions to be taken in areas including firearms capability and policy.
10 As explained in paragraphs 5 to 8 and 11 to 13 of the Coroner’s Reg. 28 report.
11 Comprising seven police forces: Bedfordshire, Cambridgeshire, Hertfordshire, Essex, Kent, Norfolk and
Suffolk.
4
20. The STRA is a living document, available in electronic format and hard copy, which is
maintained and updated following decisions made by the JSP Board. Any decisions
made by the FSG and approved by the JSP Board are added to the STRA.
21. The BCH APU recognises that, notwithstanding that it is no longer using the un-
bonded 5.56mm ammunition, the Coroner has identified three areas of concern
relating to the extent to which the BCH APU is/was aware of relevant NPCC (previously
ACPO)/CAST
such
its
recommendations.12
recommendations and
responding
systems
for
to
22. These concerns have been addressed as follows.
(1) Treating recommendations as superseding previous recommendations
23. The BCH APU is reliant on any recommendations issued by the NPCC or CAST being
disseminated to local forces and making clear on their face whether they supersede,
or are to be read in conjunction with, any previous recommendations issued by either
body.
24. All national circulars are now kept on the “POLKA” system (Police Online Knowledge
Area) which is accessible to firearms departments throughout the country. Selected
approved users have access to the site on a restricted access basis. This part of the
POLKA system is managed nationally by two Secretariats.
25.
If there is any uncertainty over the meaning of a circular, the FSG will clarify its
meaning with the NPCC and/or CAST as necessary, and record the outcome of any
such communication within the minutes and/or reports produced by the FSG.
(2) System if NPCC/CAST recommendations are not followed
26. Any decision regarding the choice and use of 5.56mm ammunition by the BCH APU
must be taken in accordance with an approved tendering process containing a
technical specification and requirement for the chosen ammunition to meet
international standards.13
27. Although the recommendations made by the NPCC (previously ACPO) are not
mandatory or binding on police forces, the BCH APU has selected the 55 grain bonded
version of the 5.56 ammunition, as recommended in the May 2012 ACPO circular, as
the most suitable ammunition for operational use.
12 Three concerns set out at paragraph 17 of the Coroner’s Reg. 28 report.
13 Such as those set by CIP (Permanent International Commission for Firearms Testing), SAAMI (the Sporting
Arms & Ammunition Manufacturers Institute) and ANSI (American National Standards Institute).
5
28. The most recent NPCC circular in July 2017 has confirmed that police forces may still
use ammunition which is not one of those recommended in the May 2012 ACPO
circular, provided that the APP-AP is complied with. The APP-AP states that in those
circumstances the chosen ammunition must “comply with international conventions
and any policy issued by ACPO” and meet operational requirements.14
29. The operational requirements outlined in the July 2017 NPCC circular involve
balancing the risk of causing serious harm or injury to the subject who is posing a
threat against the risk of harm being caused to third parties, if the bullet does not
dissipate its energy inside the subject, either from the subject not being disabled or
from the over-penetration of the bullet.15
30. As the Coroner has noted, the APP-AP does not specifically address the risk of
excessive fragmentation identified in the 2004 Nordic studies; and there is currently
no ACPO or NPCC policy or specification for 5.56mm ammunition.16
31. Accordingly, if the BCH APU were to decide to use a type of ammunition which was
not one of those recommended by the NPCC (following advice by CAST) it would need
a basis for doing so which is not currently provided by the APP-AP or any ACPO/NPCC
policy or specification.
32. All national circulars are now discussed in the quarterly FSG meetings and those
discussions are recorded in the meeting minutes. If a decision were to be taken for
the APU to select and use ammunition which is not one of the types recommended by
the NPCC or CAST, the justification and reasons for such a decision would be discussed
by the FSG along with any evidence relevant to the decision. These discussions and
any supporting evidence will be recorded in the minutes of the FSG meetings, which
are stored on the “OneNote” system.
33.
If such a decision were to be taken, the BCH APU would consult with the NPCC and/or
CAST in order to seek advice on the proposed selection of ammunition and any risks
which might be associated with it, such as the risk of excessive fragmentation
identified in the Nordic studies.
34. Any advice provided by the NPCC and/or CAST would also be discussed in the FSG
meetings and recorded in the minutes. Any correspondence with the NPCC, CAST or
any other advisory body will be recorded on the “OneNote” system.
14 See paragraph 10 above.
15 See paragraph 13 above.
16 Paragraph 13 of the Coroner’s Reg. 28 report.
6
(3) Records of decisions taken in respect of operational ammunition
35. The BCH APU recognises that all decisions bearing on the operational ammunition it
uses should be properly recorded, particularly if a decision is made to depart from
(albeit non-binding) ACPO recommendations as occurred in this case. The inquiry with
CAST in May 2012 as to whether the un-bonded 5.56mm ammunition could still be
used by the BCH APU, and the decision to continue using it, should have been
recorded on the STRA but was not.
36. Many of the difficulties encountered by the BCH APU in the present case stem from
the fact that until 2012, when the collaboration arrangement was introduced, there
was no centralised record-keeping system for the tri-force area. It was apparent
during the course of the inquest that records pre-dating 2012 were not readily
accessible to the BCH APU.
37. The decision to move to using the 55 grain tactical bonded version of the 5.56
ammunition has been recorded in the STRA for 2017-18.
38. The STRA also includes an “action log” which is reviewed every three months at the
FSG. If there are actions to be taken in response to a new circular, these will be
discussed at the FSG and the STRA action log updated accordingly.
39. As a result of the inquest, an additional provision has been added to the BCH STRA
(Appendix 10) to provide a central location for recording any decisions regarding the
including
choice of ammunition and documents relevant to those decisions,
ACPO/NPCC circulars and any correspondence with CAST. The procedures outlined in
this response (in particular paragraphs 24, 25, 32 to 34 and 38) are summarised in
Appendix 10, a copy of which can be provided to the Coroner if required.
40. All national circulars are discussed in the quarterly FSG meetings so that they can be
reviewed and responded to accordingly. National circulars have been a standing
agenda item for FSG meetings for a number of years and this will continue in response
to the Coroner’s Reg. 28 report.
41. The minutes of FSG meetings provide an audit trail and organisational memory for
subsequent decisions which are made. These records will include any decisions to
depart from the recommendations or guidance issued by the NPCC or CAST.
Conclusion
42. The BCH APU is no longer using the un-bonded 5.56mm ammunition which was used
in the present case.
7
43. However, the BCH APU recognises the concerns which have been raised regarding its
process for selecting ammunition and considering relevant, albeit non-binding,
recommendations issued by the NPCC or CAST.
44. There is currently no national policy or specification for 5.56mm ammunition although
the BCH APU understands, from the recent July 2017 NPCC circular, that the Home
Office Code of Practice on the Police Use of Firearms and Less Lethal Weapons 2003 is
being revised and will include advice on the process for evaluating ammunition.
45. The BCH APU is reliant on the NPCC and/or CAST to disseminate to local forces any
guidance they produce on the evaluation of ammunition, and making clear whether
any recommendations supersede or are to be read in conjunction with previous
recommendations. All national circulars are now kept on the “POLKA” system, which
is accessible to firearms departments throughout the country.
46. The BCH APU has amended its system of record-keeping to ensure that all decisions
relating to the selection of ammunition, and documents relevant to those decisions
including ACPO/NPCC circulars and any correspondence with CAST, are recorded on a
single electronic system: the STRA. An updated copy of the STRA has recently been
circulated to ensure officers are aware of the relevant changes.
47. All national circulars are discussed in quarterly FSG meetings and the discussions
recorded in the meeting minutes. If a decision were to be taken for the APU to use
ammunition which is not recommended by the NPCC or CAST, the BCH APU will
consult the NPCC and/or CAST. The rationale for the decision will be recorded in the
minutes of the FSG meetings and the STRA.
8
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