Duncan Tomlin

Col le e of College of Policing college police uk
g PO Box 58323
cw LONDON
Policing non on
0800 496 3322

contactus@college pnn police uk

Elisabeth Bussey-Jones

Assistant Coroner for West Sussex

3 June 2019

Dear Ms Bussey-Jones,

| am writing to explain the actions that we have taken, together with others, to address the concerns raised
in the Reg 28 Prevention of Future Deaths notice that you issued in respect of the death of Mr Duncan
Tomlin (deceased) to the College of Policing (College) dated the 12" April 2019 | was not aware of this
incident previously and | am sorry to learn of the tragic circumstances surrounding the death of Mr Tomlin
My thoughts are with his family and friends

| understand that the jury in the case of Mr Tomlin returned a narrative conclusion which found his death
was contributed to by neglect. The medical cause was found to be “cardiorespiratory failure due to both
restraint In a prone position and the effects of cocaine and mephedrone”

These findings led to you raising the following matters of concern
1 Importance of heightened risk to a person in a prone position when multiple factors affecting
breathing are present. The current and earlier training plans, manuals and policies examined as
part of the inquest evidence make clear references to risks associated with (a) positional asphyxia,
(b) handcuffs and limb restraints, (c) irritant spray, (d) acute behavioural disturbance or symptoms
thereof (e) lack of oxygen due to physical exertion, (f) drug / alcohol intoxication, and (g) seizures

Although there is some cross referencing between the various risk factors, the heightened risk to a
person in prone restraint when a number of these factors are present is not emphasised or
sufficiently emphasised The multifactorial matters that can impact on a person’s ability to breathe in
a position of prone restraint when experiencing such multiple factors are critical to the assessment of
risk

2. Timing of decisions and opportunity to assess.
A further concern relates to how officers are trained to prioritise options available to them and the
timing of decisions in circumstance similar to those tn this incident It is appreciated that officers are
not medically trained, they do make clinical decisions and a more detailed history will be taken
formally in custody suites However, officers do need to be in a positon to have sufficient information
to enable them to assess the safety of a restraint situation in which they are involved, and this
includes sharing of information and requesting information when participants in the restraint may not
have been present from the onset These points are particularly so when medical evidence suggests
fatal consequences can arise in a matter of minutes and that by the time a detainee 1s unresponsive,
action may be too late In this inquest a priority of the officers, said to be in line with their training,
was to remove the restrained person from the scene as soon as practicable The officers also gave
evidence on the risks involved in turning the detainee on his side and the possible acts that a violent
individual can take towards officers and themselves which raise other risk of harm

Cotiege of Policing Linuted 1s a company registered in England and Wales,
with registered number 8235 199 and VAT registered number 152023949
Our registered office 1s at Colteye of Policing Limited, Leamington Road,
Ryton-on-Dunsmore, Coventry CV8 3EN

However, my concern ts that in future similar situations officers may prioritise the need to act
speedily to remove a person from the scene, rather than, when a measure of control 1s obtained
(such as the use of handcuffs and limb restraints), taking the opportunity to take stock in order to
assess the detainee they are dealing with and why they are struggling or resisting Are they dealing
with a person who ts struggling because they are violent, or because they are confused, or psychotic,
or in post seizure state, or because they are in pain, uncomfortable or struggling to breathe?

Once a measure of control is obtained, speed of incidents is dictated by the actions of the officers
decide to make and balancing the risks of harm which, in the case of positional asphyxia, are fatal
and therefore must be a priority

3 Monitoring
The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in
different ways, depending on the circumstances Phrases such as close, constant, careful and
regular monitoring are used Guidance as to what constitutes monitoring does not appear to be
included within literature avaiable to officers A different type of monitoring may be required for, for
example, a detainee who poses a suicide risk or who has a known medical condition, as compared
to the type of monitoring required for a person restrained in the prone position, particularly when
affected by other factors impacting on breathing Listening to noises associated with breathing may
be entirely insufficient, particularly when they can be hard to hear, misheard or misinterpreted

4 Commencing CPR
The evidence relating to current training and training at the time of the death concerned in this
inquest indicates that CPR should commence when a person ts not breathing normally (described as
2-3 breathes in 10 seconds for and adult and 3-5 breathes for second for small children) or if
breathing is distressed (snoring, rasping) known as agonal breathing

The evidence in this jnquest was that individual officers of some experience understood CPR should
commence when breathing had stopped Whilst this may be a misunderstanding on the part of
individual officers, owing to the importance of commencing CPR at the earliest opportunity when time
1s critically of the essence, the timing of when CPR should start should be a central point of when
training CPR and when reacting to situations akin to that seen in this inquest

5. Understanding aspects of Epilepsy and Seizures
The training material that has been provided to me by Sussex Police covers many aspects of
epilepsy and seizure that were explored during this inquest. The training material indicates that if it is
available to the trainer, participants will be shown a video which informs the viewer of the way that a
person might present post seizure, namely confused, vulnerable, perceiving aggression from others
and at risk of lashing out due to misunderstanding | have also been provided with a copy of a
training manual provided by Epilepsy Action which was sent to ACPO in 2011 Aspects of the
evidence from the family in this inquest were entirely inconsistent with the less common presentation
of a person in an atypical or post seizure state

Although epilepsy was not found to be causative in this inquest, in another situation with a similar set of
circumstances, the reaction of a person suffering an atypical seizure or in post Seizure state, could be
misconstrued as violence an resistance were officers not to appreciate that fact that their presentation may
be part of a medical condition and restraint in such circumstances could have inherent and fatal risks It is
therefore of importance that training extends beyond the two more well types of seizure and that post
seizure behaviour is also understood in general terms

In responding | will explain the role of the College of Policing (the College) and what has either been done or
where work and review ts currently being undertaken In order to address each cause for concern in turn

An Overview
The College ts the professional body for policing and provides everyone working in policing with the skills
and knowledge necessary to prevent crime, protect the public and secure public trust

The College has three complementary functions:
m Knowledge developing the research and infrastructure for improving evidence of ‘what works’. Over time,
this ensures policing practice and standards are based on knowledge, not custom and convention

= Education supporting the development of individual members of the profession The College sets
educational requirements to assure the public of the quality and consistency of policing skills, and facilitate
academic accreditation and recognition of our members’ expertise.

m Standards drawing on the best available evidence of ‘what works’ to set standards in policing for forces
and individuals, for example, through authorised professional practice and peer review

The College licences Home Office Forces, including Sussex Police, to use the Personal Safety Programme
to train their staff The programme is endorsed by the National Police Chiefs Council (NPCC) Self Defence
Arrest and Restraint (SDAR) group of which the College is a member The Personal Safety Programme
uses the National Personal Safety Manual (NPSM - a secure online manual of guidance and tactical options)
and other national training products, including centrally prepared PowerPoint presentations, as its source of
training material

The College owns and publishes the NPSM in conjunction with the NPCC SDAR and the SDAR national
practitioners’ working group The SDAR are responsible for updating, developing and maintaining the NPSM
and other national training products SDAR membership includes physicians, self-defence and restraint
trainers, academics, senior managers and experts (including from the independent Office for Police
Conduct, the Home Office, the Defence science and technology laboratory and the Police Federation
amongst others) The College publishes the NPSM to the police service and then individual forces choose
the tactical options contained within it that best meet the needs of their officers and staff in responding to
local threats and deliver this through a local Personal Safety Training programme

The current recommendation to chief officers (ACPO Personal Safety Training guidelines 2009) 1s that
forces must ensure that personal safety training 1s delivered with such frequency as to maintain competence
and develop skills and knowledge As a minimum, forces must ensure that staff receive assessed refresher
and development training on an annual basis, unless an auditable risk assessment clearly identifies why this
frequency is not necessary for a particular role

The College also licences Home Office Forces, including Sussex Police to use the First Aid Learning
Programme The programme ts endorsed by the National Police Chiefs Council (NPCC) and the Health and
Safety Executive (HSE) The College of Policing 1s responsible for ensuring appropriate quality assurance
processes are in place to guide forces in the implementation of the HSE guidelines relating to the provision
of first aid

The First Aid Learning Programme has five modules and the national recommendation is that police officers
receive a minimum of Module 2 training (the equivalent to the qualification of an HSE Emergency First
Alder)

Action to address the causes for concern raised in your report:

1. Importance of heightened risk to a person in a prone position when multiple factors affecting
breathing are present.

All officers and staff are expected to be trained in and understand the medical implications that arise from

the use of force and which are contained within NPSM (Module 4) ‘medical implications +These medical

implications clearly address the risks associated with Positional Asphyxia_ They specifically include,

amongst others, the risks associated with body position, especially being in a prone position and being
unable to escape a body position and drugs/alcohol

The SDAR have historically assisted in the effective oversight and response to national issues which include
the consideration of Regulation 28 PFD reports and their matters for concern The SDAR are in the process
of considering the matters that have been raised by the tragic death of Mr Tomlin and have received medical
advice that the combination of multiple risk factors may increase the risk of positional asphyxia occurring
The SDAR will amend the existing advice with a specific safety warning to officers about this potential
increased risk

The SDAR have previously looked at the issues of Acute Behavioural Disturbance (ABD) and Positional
Asphyxiation and in 2016 produced national training tools for officers to assist them to understand and
respond to the risks involved as well as ensuring that they were properly addressed within the NPSM This
has continued to be updated as new information has become available

The SDAR are currently completing a review of the national ABD training package which Is provided through
a College PowerPoint for training in the risks of prone restraint in light of recent findings from the Terrence
Smith inquest tn Surrey and that of Mr Tomlin This will include important updates and the reinforcement of
existing good practice to help improve the safety of all Once this work has been completed, the NPCC lead
for SDAR, Deputy Assistance Commissioner (DAC) Matt Twist will write to chief officers advising them to
include this information in the Personal Safety Training programmes within their forces

2. Timing of decisions and opportunity to assess.

Dealing with individuals who are presenting a high level of aggression and agitation is extremely difficult and
officers may not be able to initially establish if the subject is resisting because they are being violent or
because they are in an agitated state due to mental iI health, a pre-existing medical condition or are
struggling to breathe The overarching principle in the use of force Is to gain control Officers will utilise the
national decision model to make an informed decision on the appropriate tactical option which will enable
them to gain control of the situation

The SDAR have considered this matter for concern and Is amending the guidance, using ‘safety boxes’, to
emphasise that, once control has been gained, officers should take an opportunity to ‘take stock’ and
reassess the risks to establish if there are any medical implications which would require any immediate
medical intervention and to follow their first aid training if this Is the case The guidance will also include a
link to Module 5 of the NPSM, ‘Personal Management’, as that includes content on how the human brain
works and of the influences of the rational and trrational mind on decision making

Advice Is given in the national ABD training package on sharing information with other emergency services
Officers are advised to utilise the ATMIST (age of subject, time of incident, mechanism of injury / medical
condition, injuries sustained or suspected, signs and symptoms and treatment given) handover to ensure
that the relevant information is passed on the medical professionals The SDAR will also be reviewing this
advice in light of the matters of concern that you have raised

3. Monitoring.

The national ABD training package contains information regarding the use of a safety officer whose sole
responsibility is to monitor the restrained subject Officers are instructed to ‘Speak up, Speak out’ and voice
their concerns, regardless of rank, if they observe any sign or symptom that could indicate that the subject is
in distress

Personal Safety Training has for many years included the role of the ‘safety officer’ who's role 1s (1) to secure
the person’s head within the multi-officer restraint techniques, and (1!) to communicate with the person to
help establish ‘calm, rapport, and control’ The overarching responsibilities of the safety officer are to monitor
the person’s breathing and visible life-signs during the restraint period, and to direct colleagues (owing to

their vantage point and ability to monitor of the person’s demeanour and welfare) during the restraint and
especially during the exit phase

Although the guidance instructs officers to monitor the subject’s airway the SDAR will further amend the
guidance to emphasise the role of the safety officer The guidance will emphasise the need for staff to
follow therr first aid training (which also contains advice on monitoring) and to act immediately if they identify
that the subject is in need of medical assistance

Additionally the SDAR will be looking at how best to amend the national ABD training package to provide
some detail of what monitoring actually means based on medical advice

4. Commencing CPR. & 5. Understanding aspects of Epilepsy and Seizures

As already mentioned the First Aid Learning Programme has five modules and the national recommendation
is that police officers receive a minimum of Module 2 training (the equivalent to the qualification of a HSE
Emergency First Aider) While Module 2 does not seek to provide coverage of all medical conditions it does
cover conducting CPR and managing a casualty who !s convulsing, as a high level learning outcome (and Is
included as part of the rolling three year refresher training process)

It is recognised within the training that, in instances where officers are required to use restraint following
suspicions of drug consumption, incidents should be dealt with as a medical emergency

The Police First Aid Programme Is monitored via both the College’s own governance and the national NPCC
portfolio The NPCC portfolio includes the Health and Safety Executive, and is supported by a dedicated
subject matter expert group of force first aid leads, and a national clinical governance structure which
includes a broad range of independent clinical expertise

Consideration of the learning from Inquests Is already a standing item on the first aid forum’s agenda and
the matters for concern raised in your report will be examined at the next scheduled meeting in July The
issues raised will also be brought to the attention of the national clinical governance panel who are also
meeting in July for their consideration

The College and NPCC will also ensure that there Is laison between the First Aid and SDAR groups that are
considering these causes for concern to ensure that advice provided to practitioners Is consistent across the
two portfolios

Summary

The College is committed to continuing its work with forces and the National Police Chiefs’ Council to raise
standards of practice in the care of suspects in detention and custody This includes their safe restraint and
care while in police custody | would like to thank you for bringing the circumstances of Mr Tomlin’s death to
our attention so that we can ensure that our future work ts informed by the events that culminated in his
death

Please let me know if you require any further information

Yours sincerely

Faculty Lead Uniformed Policing

Giles York OPM
Chief Constable

Friday 7** June 2019

Elisabeth Bussey-Jones

Assistant Coroner for West Sussex
County Record Office

Orchard Street

Chichester

West Sussex

PO19 1DD

Dear Ms Bussey-Jones,

Sussex Police Response to Regulation 28 issues arising from the inquest into
the death of Duncan TOMLIN.

Thank you for including Sussex Police within the scope of this notice. | welcome the notice as
it is vital that all public authorities learn from significant incidents and strive to learn from
them and make improvements where necessary.

It is of course important to note that the tragic death of Mr TOMLIN was in 2014 and in the 5
years since that time there have been significant developments in national police training in
this area.

| shall deal sequentially with the 5 points you raise:

1. Importance of heightened risk of prone restraint when multiple factors affecting
breathing are present

It is acknowledged that all documentation relating to training presented to the court
highlighted clear risks involved when dealing with a wide variety of issues. Any alteration to
these lesson plans will be done in conjunction with the College of Policing (CoP) through a
documented clinical process including expert involvement from the National Police Chiefs’
Council (NPCC) and National Personal Safety Training (PST) working groups.

@ 01273 404001 @giles.york@sussex.pnn.police.uk Ww @CCGilesYork
Sussex Police, Malling House, Church Lane, Lewes, East Sussex, BN7 2DZ

We are currently delivering nationally agreed training packages and any alteration to these
should be agreed nationally with approval of all parties. The benefit in delivering training
packages (for all mandatory training, not just Personal Safety Training) is they are consistent
across the UK, all police officers are trained in the most current, relevant and up to date
thinking which is designed using the latest research and learning from all Forces. We are
aware this is currently being reviewed by NPCC and any alterations passed onto Forces in
order for them to include in their training. It would be expected these alterations would be
completed by the end of 2020.

2. Timing of decisions and opportunity to assess

The College of Policing Specification document makes it clear that “where learning outcomes
require the learners to demonstrate their learning, deliverers must ensure their learners can
achieve this through the use of realistic and practical operationally-based scenarios”. In
Sussex we teach and assess monitoring as part of assessment of a casualty. Over the last
three years using practical scenarios, we operated assessments in the dark, which combines
First Aid and Personal safety scenarios with strobe lighting and loud recorded street noises.

However, it should be noted that when attending incidents officers must pause to consider a
variety of factors, one of which is their duty to protect others, (including their colleagues),
and their legal right to protect themselves. Where there is conflict in doing this, 1.e. to protect
one party may put another at an increased risk, then an informed decision using the National
Decision Model (NDM) needs to be taken that would prioritise who would receive the greater
protection. Officers are required to prioritise individuals requiring treatment at a scene
where there ts conflict and an inability to protect everyone present.

Officers are also trained in Equality, Diversity and Human Rights — Article 8 of the Human
Rights Act describes the rights of the victim in protecting their privacy and dignity. This would
also have been considered in the officer’s decision-making to remove an individual from the
scene having carried out their assessment

3. Monitoring

Monitoring is covered across a number of Lessons such as ABD, Epilepsy, conscious and
unconscious casualty and Positional Asphyxia_ The information given on monitoring breathing
in training includes more than noisy breathing — it also includes feel, touch and rise and fall of
the rib cage. This ts ncluded in the lesson plans and 1s refreshed each year.

For the last two years Sussex Police has trained and assessed each learner monitoring an
unconscious casualty who has fallen face first (another learner is the casualty during this
exercise) and point out the appearance of rise and fall looks different than those on their
backs ~ which links to those being placed in a prone position. We also use state of the art
computerised cardiopulmonary resuscitation (CPR) manikins to assess each learner
individually. This gives live accurate feedback on the effectiveness of CPR technique with
percentile scoring of both breathing and compressions This is a pass/fail assessment.

4. Commencing CPR

The training is delivered in line with College of Policing recommendations and guidelines.
Officers’ understanding of what is expected of them during the training session is tested by
practical assessments. The Force will explore whether it is practicable to also include a
knowledge test after completion of the training to ensure officers have fully understood what
has been taught and subsequently implemented in the workplace. It is hoped this review will
be completed by the end of 2019 and if a change ts proposed that this will be implemented
by the end of 2020.

Refresher training is carried out annually to ensure officers remain up to date and compliant
with their skills. A report of attendance on these refresher sessions 1s issued weekly to line
managers to ensure they are attending.

Improvements have been made in Personal Safety Training recently. Refresher training is
now delivered on a one day session twice a year. There will now be only 6 months between
refresher sessions which allows for current concerns/issues/updated training to be delivered
more regularly. It also enables the trainers to reinforce the importance of this training.

Historically, lesson plans and attendance on courses have not been archived. However, the
introduction of a new system (EQUIP) will improve this record keeping and it will be possible
to check back over a period of time to see exactly what was contained in each lesson at any
given point, as well as attendees on that learning programme. It is anticipated this will be
introduced early 2020.

5. Understanding aspects of Epilepsy and Seizures

Police officers are not trained to the level of medical practitioners. All police officers have
basic first aid training (First Aid - Module 2 of the College of Policing curriculum which
includes conducting CPR and managing a casualty who ts convulsing) which gives them the
knowledge and skills suitable for their role. It is the expectation that they recognise signs and
symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have
the knowledge of medical professionals, as the risks posed to themselves and others in trying
to take action in which they are not trained is too great Officers will carry out a dynamic risk
assessment of any risk posed by a violent individual — whether the violence ts caused by a
medical condition or otherwise — and make a decision based on that risk assessment at that
time

There have been numerous national public campaigns for individuals to identify that they
have a particular condition. This 1s not a police matter to decide, but one of public health.
Certainly this would be of benefit for officers in dealing with similar high risk situations.

In relation to epilepsy in particular, there is a video which is included in the initial officer
training course and 1s refreshed every 3 years in the refresher training. Sussex Police are
considering hosting a link to that video on their internal website for all officers to be able to
view.

1am aware that you have contacted both the NPCC and the College of Policing and that they
will be submitting separate reports. All three organisations have shared our thinking to
ensure a comprehensive and constructive response.

If there are follow-up questions about this response, please come back to myself or T/ ACC
May and | will do my best to resolve them.

Thank you again

Yours sincerely,

Giles Yo

Chief Constable QPM