Matthew Lewis

C (@) | le g e of College of Policing college.police.uk
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e e LONDON
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0800 496 3322

contactus@<ollege.pnn.police.uk

G D Hughes

HM Area Coroner
The Old Courthouse
Courthouse Street
Pontypridd

CF37 1JW

8 April 2019
Dear Mr Hughes
Re:13270, Matthew William Lewis (deceased)

| write on behalf of the College of Policing in response to the Prevention of Future Deaths report of the 13
February 2019 in relation to Matthew William Lewis (deceased) who sadly lost his life through suicide in
2018.

In the report you refer to instructions given by the police call handler which, whilst not judged to be directly or
indirectly linked to the death of Matthew Lewis, may have implications for similar future events. You express
your concern that there is a risk that a repeat of inconsistent or confusing call handler instructions may lead
to delay and potentially contribute to the prospects of an unsuccessful rescue. You also observe that training
for call handlers on how to deal with such scenarios would be desirable and mandatory.

The College of Policing produces the Nationa! Policing Curriculum which sets the learning standards for a
number of key areas of policing including contact management which informs the training of police call
handlers and dispatchers. In doing so we work closely with the National Police Chiefs Council lead for this
area, currently Assistant Chief Constable (ACC) EE from the Police Service of Northern Ireland. In
response to this report we will, within the next month, amend the learning standards for contact
management staff to reflect that the preservation of life is paramount when considering the impact on scene
preservation and that suitable instructions should be given to willing members of the public who are able to
assist in preserving life and providing rescue where possible.

| have also asked that a summary of this issue is circulated, vial to all heads of contact
management across England and Wales so that they can take any necessary urgent action in respect of
clarifying locally delivered training.

! hope that this addresses the concerns that you set out in your report and | am grateful for you bringing
them to my attention.

Yours faithfully

—=>Sersamab=

Se College of Policing Limited is a company registered in Engtand and Wales,

with registered number 8235199 and VAT registered number 152023949.
‘Our registered office is at College of Policing Limited, Leamington Road,
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CADW DE CYMRU'N DDIOGEL * KEEPING SOUTH WALES SAFE

RECEIVED
17 APR 2019

Our Reference: ACC/JG/SJ
External Telephone: 01656 762902

11" April 2019
Dear Mr Hughes,

Re: Mr Matthew William Lewis (Deceased)

| refer to your letter dated 14!" February 2019 addressed to the Chief Constable of South
Wales Police as it has been passed to me. This letter is the Regulation 29 Response on
behalf of the Chief Constable.

| have had the opportunity to consider wholly the contents of the Regulation 28 Report to
Prevent Future Deaths dated 13 February 2019 enclosed with your letter. The matters raised
therein have been fully considered by the senior officers responsible for the South Wales
Police Public Service Centre in an effort to ensure that we have addressed the concerns
raised. This arises out of the Inquest into the death of the late Mr. Mathew William Lewis.

The matters of concern you have identified are contained in section 5 of the Regulation 28
Report. | have set this out below, for ease for reference:

(1) (iii i in their evidence expressed confusion as to the instructions that
were passed to them by the call handler. in particular, whether they should approach
Mr Lewis and attempt to cut him down or refrain from doing so in the interests of scene
preservation.

(2) The subsequent evidence of the Officer in Charge, GEE was to the effect that
his primary role as a police officer was the preservation of life. The initial instructions of
the call handler here appeared inconsistent with that expressed overriding duty.

(3) In any hanging episode, time is very much of the essence following suspension. Whilst
it could not be determined on the evidence the exact time that that occurred on
27.02.18, medical evidence received at the Inquest indicated that death/irreversible
brain injury would likely occur, no later than 5 minutes post suspension. With such a
narrow “rescue window", the clarity of instructions to willing rescuers appears
paramount.
HEDDLU DE CYMRU SOUTH WALES POLICE
Pencadlys Heddlu De Cymru, Heol y Bont-faen, Penybont CF31 3SU South Wales Police Headquarters, Cowbridge Road, Bridgend CF3} 3SU
Mewn argyfwng ffoniwch 999, fel arall, ffontwch 10} In an emergency always dial 999, for non-emergencies dial {01
Gwefan: www.heddlu-de-cymru.police.uk © Website: www.south-wales.police.uk

Mae Heddlu De Cymru yn croesawu derbyn gohebiaeth yn Gymraeg a Saesneg. South Wales Police welcomes receiving correspondence in Welsh and Engtish.
Byddwn yn ateb goheblaeth a dderbynnir yn Gymraeg yn Gymracg ac ni fydd Any correspondence received in Welsh will be answered in Welsh and correspanding
gohebu yn Gymraeg yn arwaln at cedi, in Welsh will not lead to a delay in responding.

Prif Gwnstabl Matt Jukes QPM, MA(Oxon)MSc. Chief Constable

Whilst it was found on the neither evidence that the actions of the call handler were
directly, nor indirectly causative of Mr Lewis’ death, there is a risk that in the future a
repeat of confusing/inconsistent call handler instructions may lead to delay &
potentially contribute to the prospects of an unsuccessful rescue.

(4) Guidance to/training for call handlers as to how to deal with such scenarios would
seem desirable/mandated.

South Wales Police invest considerably in training call handlers to deal with a multitude of
situations; however, a training scenario can never replicate the experience gained from with
real incidents. In respect of this, | can confirm that South Wales Police have a procedure in
place for new and inexperienced call handlers, where a trainer or more experienced operator
monitors and is able to step in very quickly when the new operator is unsure of the advice
they should be giving.

In addition, whilst there is no national guidance for this type of circumstance issued by the
College of Policing to Call Handlers in Police Forces, South Wales Police has taken steps to
develop a procedure for call handlers, which incorporates appropriate guidance into its force
procedures. This new procedure is incorporated into the training that call handlers receive
and in particular, the paragraph below that highlights the presumption that ‘life is not extinct’.

“It is important to note that in any hanging scenario the emphasis is that the presumption must
always be that that life is not extinct. It is recognised that no two incidents will be the same
and there will be other factors that need to be taken into consideration. For example, the
ability of the member of the public reporting the incident to assist; or to offer assistance
without placing himself or herself in any jeopardy or danger; and the accessibility to the
location in which the person is found hanging”.

The guidance is designed for the call handler to engage with the caller in a constructive and
meaningful way to determine the appropriate level of support and assistance, which may be
provided until the arrival of the emergency services.

| hope that these actions address the points raise within your Regulation 29 notice, but if there
are any further concerns, please let me know.

Yours sincerely,

4 10G. usr
— ACC.
Jenny Gilmer
Assistant Chief Constable