Prevention of Future Deaths reports · 2018

Suleyman Yalcin

Regulation 28 report to prevent future deaths, reference 2018-0368, written 20 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Nov 2018
Reference2018-0368
DeceasedSuleyman Yalcin
CoronerAndrew Walker
Coroner areaLondon (North)
CategoryAlcohol, drug and medication related deaths · Road (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Her Majesty’s Coroner for the 
Northern District of Greater London 
(Harrow, Brent, Barnet, Haringey and Enfield) 

North London Coroners Court, 
29 Wood Street, 
Barnet EN5 4BE 

Telephone 0208 447 7680 
e-mail:-  court.clerk@hmc- 
northlondon .co.uk 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 
Commissioner of Police for the Metropolis 
Directorate of Legal Services, 
Metropolitan Police Service, 
10 Lamb's Conduit Street, 
London WC1N 3NR 

1 

CORONER 

I am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater 
London 

2 

CORONER’S LEGAL POWERS 

I 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 the 3rd December 2017 I opened an investigation following the death of Suleyman 
Yalcin on the 3rd December 2018. I opened an inquest on the 7th December 2017. The 
inquest began on the 1st October 2018. The conclusion of the inquest was “Road traffic 
collision caused directly by Suleyman Yalcin’s impaired judgement due to alcohol 
intoxication and contributed to by traffic and lighting conditions of the road at the time of 
the collision, insufficient refresher training in emergency response driving given to the 
driver of the van, police under resourcing and inadequate police terminology to describe 
the urgency of the situation to which the driver was responding”. The medical case of 
death was 1a Multiple Injuries. 

4 

CIRCUMSTANCES OF THE DEATH 

On Sunday the 3rd December 2017 at about 18.39 hrs Metropolitan Police Officers, who 
were attending an incident in Haringey, requested urgent assistance and a police van. 
Two Metropolitan Police Officers responded from Hackney Borough, as there were no 
vans available in Haringey Borough. Whilst making their way to the incident the police 
van collided with Suleyman Yalcin, who was making his way across Seven Sisters Road, 
causing fatal injuries. 

5 

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. 

 
 
 
 
 
 
 
 
 
 
 
 Her Majesty’s Coroner for the 
Northern District of Greater London 
(Harrow, Brent, Barnet, Haringey and Enfield) 

The MATTERS OF CONCERN are as follows. – 

1, Insufficient refresher training in emergency response driving given to the 
driver of the van. 
2, Police under resourcing 
3, Inadequate police terminology to describe the urgency of the situation to 
which the driver was responding. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
[AND/OR your organisation] have the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by the 11th January 2019 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons;- 

Representatives for the Met and the Family. 

I 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. 

9 

20-11-2018

Responses

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.

Response from Metropolitan Police (PDF)
DIRECTORATE OF PROFESSIONALISM 

Mr Andrew Walker, 
Senior Coroner, 
North London Coroners Court, 
29 Wood Street, 
Barnet, EN5 4BE 

Tel.: 020 8 447 7680 

Richard Martin 
Deputy Assistant Commissioner 
6th Floor 
New Scotland Yard 
Victoria Embankment 
London 
SW1A 2JL 

Email: court.clerk@hmc-northlondon.co.uk 

Email: 
Tel: 

Your ref:   
Our ref: IX/117/17 and 1802_62 

Date: 6th February 2019 

Dear Mr Walker, 

I am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police Service (MPS). 
I write in response to your Regulation 28 Report to Prevent Future Deaths dated 20th November 2018.  
Your report was sent following the conclusion of the inquest into the death of Mr Suleyman Yalcin. 

In  drafting  our  response  we  have  consulted  with  the  relevant  subject  matter  experts,  principally: 
, Met Command 
Inspector 
and  Control  (Met  CC); 
  HQ  Strategy  and  Governance;  and  the  College  of  Policing 
Authorised Professional Practice (APP). 

 Driving Academy Learning and Development; 

Response to Matters of Concern: 

1. 

Insufficient refresher training in emergency response driving given to the driver of the van. 

The  national  policy  for  police  driving  is  determined  by  the  National  Police  Chiefs’  Council 
(NPCC) Driver Training Lead. The development and maintenance of driving related national 
learning standards and supporting materials are the responsibility of the College of Policing, 
with  assistance  from  the  National  Strategic  Group  (chaired  by  the  National  Police  Driver 
Training Lead) and the practitioners’ group. Therefore national driving skills and competencies 
have been applied across all police forces. 

Prior  to  2015,  drivers  were  locally  assessed  by  an  experienced  advanced  driver  who  was 
qualified as an MPS driving assessor.  In 2015 the Roads Policing and Police Driving Learning 
Programme  set  out  national  learning  standards  for  police  driving,  including  the  delivery  of 
driver refresher training.  On 1st October 2015, the MPS Driving School introduced a three to 
five year refresher training course for all response car, covert advanced car and advanced car 
drivers;  this  is  delivered  by  a  suitably  trained  driving  instructor  and  complies  with  the 
nationally recognised APP.  By October 2020, this group of drivers will have received refresher 
training by the MPS Driving School which will complete the five year cycle.  

1 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The driver of the police van was appropriately trained to drive above the statutory speed limit, 
whilst  responding  to  an  emergency  request  for  assistance.  He  was  consequently  acting  in 
accordance with legislation, the College of Policing APP and the MPS Police Driver and Vehicle 
Policy.  

2.  Police under resourcing. 

At the inquest, the jury heard that the police van involved in the collision with Mr Yalcin was 
travelling  from  Hackney  Borough  to  an  incident  in  Haringey.    Police  vehicles  have  always 
responded  to  requests  to  support  colleagues  in  neighbouring  boroughs  during  serious 
incidents.    Resourcing  and  demand  across  the  MPS  is  constantly  reviewed  to  maintain 
operational effectiveness; this flexibility is essential in preventing crime and keeping London 
safe. 

The MPS  has  implemented  a  programme  to  incorporate  thirty  two  boroughs  into 12  Basic 
Command Units (BCUs), providing resilience and consistency across London to help the MPS 
meet its financial and operational challenges.  

Evidence  based  innovation  is  used  through  subject  matter  experts  and  working  groups  to 
update standards so police drivers remain adaptable, resilient and safe. 

3. 

Inadequate police terminology to describe the urgency of the situation to which the driver 
was responding. 

The  term  “on  the  hurry  up”  is  a  widely  used  term  within  the  police  service  and  means 
assistance  is  required  as  quickly  as  possible  due  to  officers  being  involved  in  a  volatile  or 
dangerous  situation,  for  themselves  and/or  members  of  the  public.  The  Road  Traffic 
Regulation Act 1984 and The Traffic Signs Regulations and General Directions 2016 exempt 
emergency vehicles being used for police purposes from: 

  Observing the statutory speed limit 
  Observing keep left/right signs 
  Complying with red traffic lights including pedestrian controlled crossings 

Use  of  legal  exemptions  are  applied every  day  and  the  driver must  be  able  to justify their 
actions in the pursuance of their duty. The MPS use the National Decision Model (NDM) to 
assist  operational  officers  to  risk  assess  their  response  to  a  situation  in  a  reasonable  and 
proportionate manner. The NDM provides a framework that can be applied ethically and with 
integrity to all driving decisions and actions and can be used to justify decision making when 
responding to incidents. There is no legal definition of what would or would not constitute 
justification for making use  of police  exemptions. In all considerations the NDM should be 
applied, regardless of what terminology has been used to request their assistance. It is the 
responsibility  of  the  driver  responding  to  the  call  to  make  a  determination  as  to  how  to 
respond by using the NDM.  For example, the grading of emergency calls by Met CC should 
only be used as a guide for officers and staff when deciding on the appropriate response to a 
particular call.  

The van that responded to the urgent call for assistance was driven by an experienced police 
sergeant.  He  was  aware  that  the  request  for  the  van  was  to  convey  one  of  two  suspects 
involved in a fight which had resulted in an allegation of grievous bodily harm (GBH).  There 
was clear evidence that this request required an immediate response and the driver made a 
dynamic risk assessment as to how he should proceed to the call.  

2 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 Conclusion 

As  detailed  in  this  response,  the  MPS  is  committed  to  ensuring  our  drivers  receive  training  in 
accordance with the College of Policing APP and our own driving policies. Refresher driver training is 
provided every three to five years in accordance with national learning standards for police driving. 
Resourcing  and  demand  across  the  MPS  is  constantly  reviewed  to  maintain  our  operational 
effectiveness. 

Whilst we recognise the use of MPS terminology, we will seek to remind our staff that if required, 
further clarification should be sought to justify the request. The MPS are committed to enhancing our 
training and this will be incorporated in Met CC professional development days and initial training for 
all operational staff. 

Yours sincerely, 

Richard Martin 
Deputy Assistant Commissioner 

3 | P a g e
Response from Metropolitan Police2 (PDF)
METROPOLITAN

POLICE
PROFESSIONALISM HQ

Mr Andrew Walker,

HM Senior Coroner,

North London Coroners Court,
29 Wood Street,

Matthew Horne

Deputy Assistant Commissioner
6" Floor

New Scotland Yard

Barnet, EN5 4BE Victoria Embankment
London

Tel.: 020 8447 7680 SW1A 2JL

Email: court.clerk@hmc-northlondon.co.uk i
Tel: -
Your ref:

Our ref: IX/117/17 and 1802_62

Date: 3 May 2019

| refer to Miss Rebecca Smith’s e-mail dated 1% April 2019 in which she seeks clarity on DAC
Martin’s response to your Regulation 28 report following the death of Mr Suleyman Yalcin on
the 3° December 2017. | have succeeded DAC Martin as Deputy Assistant Commissioner
Professionalism within the Metropolitan Police Service (MPS) and respond to you in this
capacity.

Response to Matters of Concern:

1. Insufficient refresher training in emergency response driving given to the driver
of the van.

a 2: a qualified response driver under the MPS Driving Policy and
training regime in place prior to 1st October 2015. The regime in place at the time
comprised of ‘check tests’ being conducted by qualified officers. iy
completed this in line with the then policy. He is due to receive his next refresher
training later this year in accordance with the new MPS Driving Policy, which adheres
to the College of Policing’s Roads Policing and Police Driving Learning Programme.
All MPS officers now undertake refresher training every 3 to 5 years. | trust that this
new regime of refresher training addresses your matter of concern.

2. Police under resourcing.

The MPS seeks to balance available resources at times against operational demand,
and flexing resources to respond to peaks and critical issues. Since 2017 the MPS has
undergone a significant restructure with the implementation of the Basic Command
Unit (BCU) model with the final phase being completed in February 2019. The
responsibility of implementing the model and operational delivery lies with local

1|Page

leadership teams, ultimately BCU Commanders. This has enabled a greater level of
flexibility to deploy resources across borough boundaries as one policing command
areas spans between two and four London boroughs.

This policing restructure allows us to make best use of our available resources and the
BCU’s will constantly review the availability of officer to respond to incidents.

3. Inadequate police terminology to describe the urgency of the situation to which
the driver was responding.

Since DAC Martin's response dated 6" February 2019 | have been updated that our
Command and Control Centre (MetCC) informed all call handlers to remind them to
always clarify the reason for their request and record this on the Computer Aided
Despatch system. This issue has also been incorporated into their professional
development days (training days) which started on 5th February 2019. Call despatch
courses now include a session on clarifying terminology in these situations.

The use of the terminology ‘on the hurry up’, is a recognised use of language to request
additional support and assistance at the scene of an incident. It is MetCC’s
responsibility to command and control police radio communications; this involves
clarifying the reasons for the request and deploying units according to urgency, risk
and operational priorities. The MPS does not propose to a change in the language,
but clarity as to the specific needs is now incorporated into the revised training above.

If you have any further queries, please do not hesitate to contact me.

Yours sincerely,

Matthew Horne
Deputy Assistant Commissioner

2|Page

Related reports

Other reports by Andrew Walker

See all →

More reports categorised “Alcohol, drug and medication related deaths”

See all →

Track Alcohol, drug and medication related deaths

See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.